Diabetes is a metabolic disease that causes high blood glucose or blood sugar. Under normal circumstances, the hormone insulin is responsible for transporting sugar from the bloodstream into the cells to be used for energy or stored for later use. In people with diabetes, though the body fails to either make sufficient insulin or it is unable to effectively use the insulin that it is producing.1
If left untreated, high blood sugar due to diabetes can, over time, cause damage to the eyes, nerves, kidneys, and other organs of the body. Diabetes also increases the risk of developing various bone and joint disorders, including tendonitis. This happens because of factors like nerve damage, obesity, and arterial disease.2
Can Diabetes Cause Tendon Problems?
Many people with diabetes often complain that it hurts when they move. This is usually due to problems with the tendons. Tendons are cord-like bands of fibrous tissue that connect your muscles to your bones. When a person has chronic high blood sugar due to diabetes, it may become a cause of tendon or bone and joint problems.3
There are tendons present all over your body, including your hips, knees, arms, shoulders, wrists, and ankles. The tendons are responsible for transferring the force from the muscles to the bones, thus allowing you to move. When your diabetes is not well managed, and under control, it can cause your tendons to thicken. This increases the likelihood of the tendons tearing at the slightest force.4
The Link Between Diabetes & Tendon Problems
People with type 1 and type 2 diabetes often experience tendon damage because of advanced glycation end products, or AGEs. AGEs are substances that are formed when fat or protein mixes with sugar or glucose in the bloodstream.5,6,7 Under normal conditions, the body manufactures AGEs at a slow and steady rate. However, in people with diabetes, the extra glucose or sugar in the bloodstream boosts up the speed of production of these AGEs, which affects the tendons.8
Tendons are made from collagen, which is a type of protein. AGEs can form a bond with collagen and change the basic structure of the tendon, thus affecting how well they are able to work. For example, the bonding of AGEs with the collagen can cause the tendons to be thicker than they usually are. They might not be able to hold up as much weight as they are meant to, or they are used to. Due to this, the odds of experiencing a tear in one or more of your tendons go up significantly.9
Some of the common tendon problems you may experience if you don’t keep your diabetes under control include:
Frozen shoulder, also known as adhesive capsulitis, happens when the ligaments around the shoulder joint become inflamed and stiff. The inflammation of the shoulder joint and surrounding ligaments make it difficult for normal healing to take place, resulting in the shoulder becoming stiff. This can make it challenging to even do everyday activities, even small actions like buttoning up your shirt.10
Frozen shoulder is a very painful condition. This is usually also followed by increasing stiffness after around nine months of having the condition. Symptoms of frozen shoulder also tend to get worse over time and can eventually go on to affect movement. Patients with frozen shoulder can alleviate their symptoms with medications and home remedies, but it can take several years to get any relief.11
Research has found that people with diabetes are almost twice as likely to suffer from frozen shoulder due to the effects of AGEs on collagen present in the shoulder.
When the sugar molecules get attached to the collagen, the collagen can become sticky, leading to restricted movement, and the shoulder starts to stiffen. This process is called glycosylation.12 Poorly managed diabetes has been linked to various skeletal and muscular problems.
Chronic high blood sugars are known to increase the risk of developing diabetes-related complications like frozen shoulder.
Pain and stiffness are the two main symptoms of frozen shoulder, and these symptoms tend to vary from being mild to severe enough that you may eventually not be able to move your shoulder easily. Symptoms of frozen shoulder typically affect people in three stages, which include:13
- Stage One: Freezing – Stage one lasts for six weeks to about nine months. During this time, the shoulder will become very painful, and it can also lead to a loss in the range of motion.
- Stage Two: Frozen: This stage can last for anywhere between four to 12 months. During this period, you may find some relief in the pain, but the shoulder stiffness is going to continue to increase.
- Stage Three: Thawing: This stage lasts for around six months to several years. During stage three, you will find it easier to move your shoulder, and you may again start doing your everyday tasks without pain and stiffness.
People can experience a lot of difference in their symptoms, but an early diagnosis of frozen shoulder and treatment can decrease the severity of the symptoms.
Rotator Cuff Tear
Another common condition that affects people with diabetes is a rotator cuff tear. A rotator cuff tear happens when there is a rip in the group of four muscles and tendons that surround the shoulder joint and work to stabilize the shoulder joint. These muscles and tendons help you lift and rotate your arms. A rotator cuff tear is also known as a full-thickness tear or a complete tear.
Rotator cuff tears are one of the most common causes of shoulder disability in people who have diabetes and are above the age of 50 years.14 Surgical intervention is usually required for restoring function to the rotator cuff.
Having a rotator cuff tear and continuing to leave it untreated can not only increase your pain, but it can also cause further damage. If left untreated, a rotator cuff tear will keep getting larger over time. In a majority of people, non-surgical treatment can help relieve pain and also improve the functioning of the shoulder. Non-surgical treatment options include rest, avoiding activities that cause shoulder pain, using nonsteroidal anti-inflammatory medications like ibuprofen and naproxen, physical therapy, joint strengthening exercises, and steroid injections if medications don’t work.15
Trigger finger is a musculoskeletal condition that affects the ligaments and tendons in the thumb or fingers. In this condition, the thumb or a finger gets stuck in a bent position and then straightens with a snap. The snap is why the condition is called a trigger finger as it sounds like a trigger has been pulled and then suddenly released. In severe cases, though, the finger may become locked in the bent position itself.16
The condition only affects two to three percent of the population, but 10 to 20 percent of people with diabetes are more likely to have this. The onset of a trigger finger is also associated with how long you have had diabetes and your age. However, it is not associated with blood glucose control. In people with type 1 diabetes, the trigger finger is known to be also linked with carpal tunnel syndrome.17
Carpal Tunnel Syndrome
Also known as median nerve compression, carpal tunnel syndrome is a condition that causes weakness, tingling, or numbness in the hand. This happens because of pressure on the median nerve. The median nerve runs through the length of your arm, passing through a passage in the wrist known as carpal tunnel, and finally ending in the hand. The median nerve controls the feeling and movement of the thumb and all the fingers except the pinky.18
Carpal tunnel syndrome is another potential complication of diabetes, and the longer you have diabetes, the higher are the chances of developing carpal tunnel syndrome. At the same time, researchers have discovered that having carpal tunnel syndrome is also a predictor for developing diabetes.19
The exact association between diabetes and carpal tunnel syndrome is not precisely understood. Still, it is known that people with diabetes are more prone to carpal tunnel syndrome, even those individuals who don’t have diabetic nerve complications.20
According to the UK Diabetes Community, carpal tunnel syndrome is reported in nearly 15 to 20 percent of all people with diabetes. Research suggests that the link between carpal tunnel syndrome and diabetes could be due to chronic excessively high blood sugar levels. This can lead to the carpal tunnel tendons getting glycosylated, a condition that happens when the blood glucose attaches to the proteins of the tendons and restricts the tendons from moving freely.21
It is possible that even many years before you get an actual diagnosis of diabetes, the overly high levels of blood sugar may have already started affecting the body. In people who get a diagnosis of carpal tunnel syndrome and don’t have diabetes, the development of carpal tunnel could actually be an indication of a future diabetes diagnosis.
A study carried out at London’s King’s College found that people initially diagnosed with only carpal tunnel syndrome were 36 percent more likely to be diagnosed with diabetes in the future. This was found to be true regardless of any of the other risk factors commonly associated with diabetes.22
The common symptoms of carpal tunnel syndrome can affect the entire hand but usually involves:
- The index finger
- The middle finger
- The thumb
If you feel numbness, pain, or a tingling sensation in these fingers, along with half of the ring finger, but not on the little finger, then this could be a sign that you have carpal tunnel syndrome. This happens because feelings and sensations to the little finger are supplied by different nerves.
The symptoms may begin with just one hand but often affect both the hands eventually. The symptoms can sometimes also extend beyond the affected area through which the median nerve pass, thus causing pain in the arm.
Other Tendon-related Problems
Diabetic Hand Syndrome: Diabetic hand syndrome, also known as diabetic cheiroarthropathy, is a condition in which the skin of the hands start becoming thickened and waxy. Over time, finger movement gets severely restricted. The cause of diabetic hand movement is unknown, but it is more commonly observed in people who have diabetes for a long time. The main symptom of diabetic hand syndrome is an inability to completely extend your fingers or press your palms flat together. Better management of your blood sugar levels, along with physical therapy, helps slow down the progress of this condition, but the restricted mobility of the hand is usually not reversible.23,24
Dupuytren’s Contracture Disease: Dupuytren’s Contracture, or Dupuytren’s disease, is a condition that causes abnormal tightening and thickening of the ordinarily flexible and loose tissue beneath the skin of the palm and fingers. The ring and small fingers are the most affected. While both hands are usually affected, one is typically affected worse than the other. The thickening of the tissue under the skin of the hand causes the fingers to bend inside towards the palm. Dupuytren’s Contracture is common in people who have had diabetes for a long time because of the metabolic changes that are related to diabetes. It begins with mild thickening of the skin on the palm, and eventually, you may not be able to straighten one or more of your fingers.25
Diffuse Idiopathic Skeletal Hyperostosis (DISH): Also known as Forestier disease, DISH causes hardening of tendons and ligaments that affects the spine. DISH is commonly associated with type 2 diabetes because of insulin or insulin-like growth factors that boost new bone growth.26 People with DISH may experience stiffness, pain, or a reduced range of motion in the affected part of the body. DISH can be treated with pain relievers or surgical intervention in rare cases.
How to Prevent and Treat Tendon Damage with Diabetes?
The best way to prevent tendon problems is to keep your diabetes under control. Keep your blood sugar under control with the help of a healthy diet, regular exercise, and the medications your doctor has prescribed. If you are overweight, losing some weight can help you better manage your condition. It will also improve your overall health and take some of the strain off your tendons.
In people with diabetes who already have tendon damage, here are some standard solutions to alleviate the pain and other symptoms:
- Apply heat or ice to the affected area
- Take muscle relaxants or pain relievers like ibuprofen or aspirin, but only after consulting your doctor.
- Physical therapy and regular exercise
- A splint for keeping the joint steady while allowing the tendons to heal
In severe cases, your doctor may suggest a steroid injection into the joint to relieve the tendon problems. However, it is essential to keep in mind that steroids can lead to a short-term spike in blood sugar levels.
Regular exercise is essential in managing tendon problems, and it can also help keep your diabetes under control. Talk to your doctor about different ways of keeping your blood sugar levels under control as you recover from tendon problems. Remember, managing your diabetes properly can prevent several complications of diabetes.
- Mellitus, D., 2005. Diagnosis and classification of diabetes mellitus. Diabetes care, 28(S37), pp.S5-S10.
- Nathan, D.M., Zinman, B., Cleary, P.A., Backlund, J.Y.C., Genuth, S., Miller, R., Orchard, T.J., Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Research Group, 2009. Modern-day clinical course of type 1 diabetes mellitus after 30 years’ duration: the diabetes control and complications trial/epidemiology of diabetes interventions and complications and Pittsburgh epidemiology of diabetes complications experience (1983-2005). Archives of internal medicine, 169(14), p.1307.
- Almekinders, L.C. and Temple, J.D., 1998. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Occupational Health and Industrial Medicine, 5(39), p.236.
- Grant, W.P., Sullivan, R., Sonenshine, D.E., Adam, M., Slusser, J.H., Carson, K.A. and Vinik, A.I., 1997. Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. The Journal of foot and ankle surgery, 36(4), pp.272-278.
- Vlassara, H. and Striker, G.E., 2013. Advanced glycation endproducts in diabetes and diabetic complications. Endocrinology and Metabolism Clinics, 42(4), pp.697-719.
- Peppa, M., Uribarri, J. and Vlassara, H., 2003. Glucose, advanced glycation end products, and diabetes complications: what is new and what works. Clinical Diabetes, 21(4), pp.186-187.
- Ahmed, N., 2005. Advanced glycation endproducts—role in pathology of diabetic complications. Diabetes research and clinical practice, 67(1), pp.3-21.
- Li, Y., Fessel, G., Georgiadis, M. and Snedeker, J.G., 2013. Advanced glycation end-products diminish tendon collagen fiber sliding. Matrix Biology, 32(3-4), pp.169-177.
- Gautieri, A., Passini, F.S., Silván, U., Guizar-Sicairos, M., Carimati, G., Volpi, P., Moretti, M., Schoenhuber, H., Redaelli, A., Berli, M. and Snedeker, J.G., 2017. Advanced glycation end-products: mechanics of aged collagen from molecule to tissue. Matrix biology, 59, pp.95-108. Dias, R., Cutts, S. and Massoud, S., 2005. Frozen shoulder. Bmj, 331(7530), pp.1453-1456.
- Shaffer, B., Tibone, J.E. and Kerlan, R.K., 1992. Frozen shoulder. A long-term follow-up. JBJS, 74(5), pp.738-746.
- Yian, E.H., Contreras, R. and Sodl, J.F., 2012. Effects of glycemic control on prevalence of diabetic frozen shoulder. JBJS, 94(10), pp.919-923.
Hsu, C.L. and Sheu, W.H.H., 2016. Diabetes and shoulder disorders. Journal of diabetes investigation, 7(5), p.649.
- Huang, S.W., Wang, W.T., Chou, L.C., Liou, T.H., Chen, Y.W. and Lin, H.W., 2016. Diabetes mellitus increases the risk of rotator cuff tear repair surgery: a population-based cohort study. Journal of Diabetes and its Complications, 30(8), pp.1473-1477.
- Ramme, A.J., Robbins, C.B., Patel, K.A., Carpenter, J.E., Bedi, A., Gagnier, J.J. and Miller, B.S., 2019. Surgical versus nonsurgical management of rotator cuff tears: a matched-pair analysis. JBJS, 101(19), pp.1775-1782.
- Blyth, M.J.G. and Ross, D.J., 1996. Diabetes and trigger finger. The Journal of Hand Surgery: British & European Volume, 21(2), pp.244-245.
Chammas, M., Bousquet, P., Renard, E., Poirier, J.L., Jaffiol, C. and Allieu, Y., 1995. Dupuytren’s disease, carpal tunnel syndrome, trigger finger, and diabetes mellitus. The Journal of hand surgery, 20(1), pp.109-114.
- Gelberman, R.H., Hergenroeder, P.T., Hargens, A.R., Lundborg, G.N. and Akeson, W.H., 1981. The carpal tunnel syndrome. A study of carpal canal pressures. JBJS, 63(3), pp.380-383.
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