Intrinsic muscle atrophy in diabetes

NewsBot · Nov 27, 2007

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Atrophy of Foot Muscles in Diabetic Patients Can Be Detected With Ultrasonography
Kaare Severinsen, Annette Obel, Johannes Jakobsen and Henning Andersen
Diabetes Care 30:3053-3057, 2007

OBJECTIVE—To establish a bedside test with ultrasonography for evaluation of foot muscle atrophy in diabetic patients.

RESEARCH DESIGN AND METHODS—Thickness and cross-sectional area (CSA) of the extensor digitorum brevis muscle (EDB) and of the muscles of the first interstitium (MILs) were determined in 26 diabetic patients and in 26 matched control subjects using ultrasonography. To estimate the validity, findings were related to the total volume of all foot muscles determined at magnetic resonance imaging (MRI-FMvol). Furthermore, the relations of ultrasonographic estimates to nerve conduction, sensory perception thresholds, and clinical condition were established.

RESULTS—In diabetic patients, the ultrasonographic thickness of EDB (U-EDBt) was (means ± SD) 6.4 ± 2.1 vs. 9.0 ± 1.0 mm in control subjects (P < 0.001), the thickness of MIL (U-MILt) was 29.6 ± 8.3 vs. 40.2 ± 3.6 mm in control subjects (P < 0.001), and the CSA of EDB (U-EDBCSA) was 116 ± 65 vs. 214 ± 38 mm2 in control subjects (P < 0.001). The MRI-FMvol was directly related to U-EDBt (r = 0.77), U-MILt (r = 0.71), and U-EDBCSA (r = 0.74). U-EDBt and U-MILt were thinner in neuropathic than in nonneuropathic diabetic patients (5.8 ± 2.1 vs. 7.5 ± 1.7 mm [P < 0.05] and 28.3 ± 8.8 vs. 35.6 ± 4.3 mm [P < 0.03], respectively).

CONCLUSIONS—Atrophy of intrinsic foot muscles determined at ultrasonography is directly related to foot muscle volume determined by MRI and to various measures of diabetic neuropathy. Ultrasonography seems to be useful for detection of foot muscle atrophy in diabetes.
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Admin2 · Nov 27, 2007

Related thread:
Foot Small Muscle Atrophy Is Present Before the Detection of Clinical Neuropathy

Admin2 · Nov 27, 2007

There was this 2002 paper on the same topic:

Intrinsic Muscle Atrophy and Toe Deformity in the Diabetic Neuropathic Foot
A magnetic resonance imaging study
Sicco A. Bus, Qing X. Yang, Jinghua H. Wang, Michael B. Smith, Roshna Wunderlich, and Peter R. Cavanagh
Diabetes Care 25:1444-1450, 2002

OBJECTIVE—The objectives of this study were to compare intrinsic foot muscle cross-sectional area (CSA) in patients with diabetic polyneuropathy and nondiabetic control subjects and to examine the association between intrinsic muscle CSA and clawing/hammering of the toes in neuropathic feet.

RESEARCH DESIGN AND METHODS—High-resolution T2-weighted fast spin-echo images and parametric T2 multiple spin-echo images were acquired using multiple spin-echo magnetic resonance imaging (MRI) of frontal plane sections of the metatarsal region of the foot in a sample of eight individuals with diabetic polyneuropathy and eight age- and sex-matched nonneuropathic nondiabetic control subjects. The configuration of joints of the second toe was obtained using a three-dimensional contact digitizer.

RESULTS—Remarkable atrophy was found in all the intrinsic muscles of neuropathic subjects as compared with nondiabetic control subjects. Quantitative T2 analysis showed a 73% decrease in muscle tissue CSA distally in the neuropathic subjects. Muscle comprised only 8.3 ± 2.9% (means ± SD) of total foot CSA compared with 30.8 ± 3.9% in control subjects. No significant differences were found between the groups in the metatarso-phalangeal and proximal and distal interphalangeal joint angles of the second ray. Moreover, clawing/hammering of the toes was found in only two of eight neuropathic subjects.

CONCLUSIONS—Although sensory neuropathy is often emphasized in considerations of diabetic foot pathology, our results show that the consequences of motor neuropathy in the feet are profound in people with diabetes. This has implications for foot function and may play a significant role in postural instability. However, intrinsic muscle atrophy does not necessarily appear to imply toe deformity.
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NewsBot · Mar 13, 2009

The role of intrinsic muscle atrophy in the etiology of claw toe deformity in diabetes may not be as straightforward as widely believed.
Bus SA, Maas M, Michels RP, Levi M.
Diabetes Care. 2009 Mar 11. [Epub ahead of print]

Objective: Clawing of the toes in the diabetic neuropathic foot is believed to be caused by muscle imbalance resulting from intrinsic muscle atrophy. However, experimental data that supports this mechanism is lacking. The aim of this study was to evaluate this hypothesis using magnetic resonance imaging (MRI).

Research Design and Methods: In twenty neuropathic diabetic patients, ten with claw toe deformity and ten with normally aligned toes, multiple plane images of the foot and lower leg were acquired using T1-weighted spin-echo MRI. Atrophy of the intrinsic and extrinsic muscles controlling the toes were assessed using a semi-quantitative 5-point atrophy scale. An intrinsic-to-extrinsic foot muscle imbalance score was derived from these atrophy scores and correlation coefficients were established.

Results: Mean (SD) intrinsic muscle atrophy score was 3.1 (1.1) for the toe deformity group and 2.6 (1.2) for the non-deformity group (not significantly different). Intrinsic muscle atrophy score was not correlated with degree of toe deformity (r = -0.18). Muscle imbalance score was not significantly different between study groups and not correlated with degree of toe deformity (r = -0.14).

Conclusions: Neither intrinsic muscle atrophy nor muscle imbalance discriminated between neuropathic patients with or without claw toe deformity. This suggests that the role of these muscle factors in claw toe development may not be primary or as straightforward as previously believed. These findings shed new light on the etiology of foot deformity in diabetes and suggest a more complex nature of development, potentially involving anatomical and physiological predisposing factors.
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NewsBot · Jun 11, 2009

Foot Muscle Energy Reserves In Diabetic Patients Without And With Clinical Peripheral Neuropathy.
Dinh T, Doupis J, Lyons TE, Kuchibhotla S, Julliard W, Gnardellis C, Rosenblum BI, Wang X, Giurini JM, Greenman RL, Veves A.
Diabetes Care. 2009 Jun 9. [Epub ahead of print]

Objective. To investigate changes in the foot muscle energy reserves in diabetic non-neuropathic and neuropathic patients. Research Design and Methods. We measured the phosphocreatinine/inorganic phosphate (PCr/Pi) ratio, total (31)P concentration and the Lipid/Water ratio in the muscles in the metatarsal head region using MRI spectroscopy in healthy control subjects and non-neuropathic and neuropathic diabetic patients. Results. The PCr/Pi ratio was higher in the controls (3.23 +/- 0.43) followed by the non-neuropathic group (2.61 +/- 0.36) while it was lowest in the neuropathic group (0.60 +/- 1.02) (p <0.0001). There were no differences in total (31)P concentration and Lipid/Water ratio between the control and non-neuropathic groups but both measurements were different in the neuropathic group (p <0.0001). Conclusions. Resting foot muscle energy reserves are affected before the development of peripheral diabetic neuropathy and are associated with the endothelial dysfunction and inflammation.
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NewsBot · Oct 21, 2013

From Lower Extremity Review:
Imaging reveals intrinsic muscle deterioration in neuropathic feet

NewsBot · Nov 2, 2013

Intrinsic foot muscle deterioration is associated with metatarsophalangeal joint angle in people with diabetes and neuropathy.
Cheuy VA, Hastings MK, Commean PK, Ward SR, Mueller MJ.
Clin Biomech (Bristol, Avon). 2013 Oct 12.

BACKGROUND:
Metatarsophalangeal joint deformity is associated with skin breakdown and amputation. The aims of this study were to compare intrinsic foot muscle deterioration ratios (ratio of adipose to muscle volume), and physical performance in subjects with diabetic neuropathy to controls, and determine their associations with 1) metatarsophalangeal joint angle and 2) history of foot ulcer.
METHODS:
23 diabetic, neuropathic subjects [59 (SD 10) years] and 12 age-matched controls [57 (SD 14) years] were studied. Radiographs and MRI were used to measure metatarsophalangeal joint angle and intrinsic foot muscle deterioration through tissue segmentation by image signal intensity. The Foot and Ankle Ability Measure evaluated physical performance.
FINDINGS:
The diabetic, neuropathic group had a higher muscle deterioration ratio [1.6 (SD 1.2) vs. 0.3 (SD 0.2), P<0.001], and lower Foot and Ankle Ability Measure scores [65.1 (SD 24.4) vs. 98.3 (SD 3.3) %, P<0.01]. The correlation between muscle deterioration ratio and metatarsophalangeal joint angle was r=-0.51 (P=0.01) for all diabetic, neuropathic subjects, but increased to r=-0.81 (P<0.01) when only subjects with muscle deterioration ratios >1.0 were included. Muscle deterioration ratios in individuals with diabetic neuropathy were higher for those with a history of ulcers.
INTERPRETATION:
Individuals with diabetic neuropathy had increased intrinsic foot muscle deterioration, which was associated with second metatarsophalangeal joint angle and history of ulceration. Additional research is required to understand how foot muscle deterioration interacts with other impairments leading to forefoot deformity and skin breakdown.
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NewsBot · Aug 12, 2014

Early Detection of Atrophy of Foot Muscles in Chinese Patients of Type 2 Diabetes Mellitus by High-Frequency Ultrasonography,
Xiaohui Wang, Liang Chen, Weiwei Liu, Benli Su, and Yuhong Zhang
Journal of Diabetes Research, Volume 2014 (2014), Article ID 927069, 6 pages

The aim of this study was to evaluate the diagnostic value of high-frequency ultrasonography in detecting atrophy of foot muscles in Chinese patients of type 2 diabetes mellitus (T2DM). Chinese patients of T2DM with () or without () diabetic peripheral neuropathy (DPN) and the control subjects () were enrolled. The nondominant foot of all subjects was examined with high-frequency ultrasonography. The transverse diameter, thickness, and cross-sectional area of the extensor digitorum brevis muscle (EDB) and the thickness of the muscles of the first interstitium (MILs) were measured. The results showed that the ultrasonographic transverse diameter, thickness, and cross-sectional area of EDB and the thickness of MILs in patients of T2DM with DPN were significantly smaller than those in patients of T2DM without DPN (all ) and those in the control subjects (all ). The transverse diameter and cross-sectional area of the EDB and thickness of MILs in patients of T2DM without DPN were significantly smaller than those of the control subjects (all ). In conclusion, the atrophy of foot muscle in Chinese T2DM patients can be detected by high-frequency ultrasonography. Notably, ultrasonography may detect early atrophy of foot muscles in patients without DPN.
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NewsBot · Dec 20, 2014

Intrinsic Foot Muscle And Plantar Tissue Changes In Type 2 Diabetes Mellitus
Chanamgere Govindappa Shashi Kumar PhD Scholar, Kadavigere Venkatachalaiah Rajagopal Professor and head, H Manjunath Hande Professor and Unit head, Arun G Maiya Professor & Dr.TMA PAI Chair and Shreemathi S Mayya Associate professor
Journal of Diabetes

Important findings of the study: The present study highlights the early intrinsic foot muscle and plantar tissue changes in T2DM with and without PN. The early changes could be the ace of the risk components for developing complications like callus and intrinsic claw in the diabetic foot.

This study adds: The present study contributes data about how diabetes mellitus affects patient's foot subjecting them to risk of developing foot complications. The study provides evidence to the fact that structural changes likely to occur can be evaluated and many foot complications can be prevented at the early stage of disease.
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Objective
Diabetes mellitus is a metabolic disorder with involvement of the neurovascular and muscular system. Peripheral neuropathy (PN) is thought to be the principal cause for foot complications in type 2 diabetes mellitus (T2DM). However, early in the course of diabetes foot evaluation using ultrasonography has not gained due importance.

Method
Study was conducted with 30 T2DM with and without PN and 30 age matched non diabetes mellitus (NDM) subjects. After detailed clinical evaluation high frequency musculoskeletal ultrasonography was used to measure thickness of intrinsic foot muscles and plantar tissue thickness under the metatarsals. Data was analysed using independent “t” test to compare between T2DM groups with NDM subjects. One way ANOVA followed by a Post hoc test (Tukey HSD) was applied to analyse between and within the groups.

Results
In the present study, we observed significant reduction in the thickness of the intrinsic foot muscles and plantar tissue in T2DM subjects compared to NDM subjects (p<0.05). However, there was no changes in the intrinsic foot muscle and plantar tissue thickness between T2DM subjects with PN and without PN,

Conclusion
In the present study, we noted a substantial decrease in intrinsic foot muscles and plantar tissue thickness in T2DM subjects as compared to NDM subjects. This reasons out that structural changes in the foot in an antecedent to clinically apparent PN. Techniques employed in this study cannot exclude the possibility that neuropathic changes undetectable clinically may develop in parallel with changes in plantar tissues.
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NewsBot · Apr 16, 2016

MRI assessment of regional differences in phosphorus-31 metabolism and morphological abnormalities of the foot muscles in diabetes.
Lin YC et al
J Magn Reson Imaging. 2016 Apr 15

PURPOSE:
To assess differences in the phosphorus-31 (31 P) metabolism and morphology in multiple muscle regions in the forefoot of diabetic patients and normal subjects.
MATERIALS AND METHODS:
Fifteen diabetic patients and 15 normal subjects were assessed for muscle atrophy by 1 H magnetic resonance imaging (MRI) at 3T to grade the flexor hallucis, adductor hallucis, interosseous regions, and entire foot cross-section. Each region and the entire foot were also quantitatively evaluated for metabolic function using 31 P imaging for spatial mapping of the inorganic phosphate (Pi) to phosphocreatine (PCr) ratio (Pi/PCr). The ratio of viable muscle area to the predefined region areas (31 P/1 H) was calculated. The variability of each method was assessed by its coefficient of variation (CV).
RESULTS:
Muscle atrophy was significantly more severe in diabetic compared to normal subjects in all regions (P < 0.01). The 31 P/1 H area ratio was significantly larger in the adductor hallucis than in the other two regions (P < 0.05). The Pi/PCr ratio was significantly different between the two groups in the flexor hallucis and interosseous regions (P < 0.05) but not adductor hallucis region. The CV for Pi/PCr ranged from 10.13 to 55.84, while it ranged from 73.40 to 263.90 for qualitative grading.
CONCLUSION:
Changes in atrophy and metabolism appear to occur unequally between different regions of the forefoot in diabetes. The adductor hallucis region appears more capable of maintaining structural and metabolic integrity than the flexor hallucis or interosseous regions. The CV analysis suggests that the quantitative 31 P methods have less variability than the qualitative grading.
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NewsBot · Jun 18, 2018

Can ultrasound measures of intrinsic foot muscles and plantar soft tissues predict future diabetes-related foot disease? A systematic review.
Morrison T, Jones S, Causby RS, Thoirs K
PLoS One. 2018 Jun 15;13(6):e0199055. doi: 10.1371/journal.pone.0199055. eCollection 2018.

INTRODUCTION:
Diabetes mellitus (DM) is associated with hyperglycaemia and advanced glycosylation end-products. In the foot, the consequences of chronic or uncontrolled diabetes are micro and macrovascular disease, neuropathy, reduced joint mobility and structural and soft tissue changes that increase the risk of ulcer development and amputation. Diabetes foot assessment currently includes a comprehensive history, neurological and vascular assessments and examination focussed on dermatological and musculoskeletal abnormalities. Whilst these assessments are helpful for predicting ulceration risk, direct identifiers that enable early therapeutic intervention are lacking. The intention of this review was to ascertain if B-mode ultrasound could be clinically applied to identify structural change in the diabetic foot and be utilised as an early predictor of ulceration risk.

METHODS:
Primary databases and grey literature sources were systematically searched. Selection criteria were that the study included a diabetic sample and used B-mode ultrasound to assess soft tissue structures of the foot (plantar skin, plantar fat pad or intrinsic muscles).

RESULTS:
Fifteen studies were identified for inclusion (combined diabetic sample of 773). Ultrasound demonstrated reductions in tissue thickness in diabetics compared to non-diabetics under first (p = 0.01) and second (p = 0.03) metatarsal heads, but not the third (p = 0.24). Statistical heterogeneity was high for ultrasound thickness measures under metatarsal heads four/five (I2 65%, 81%) and very high for plantar skin (I2 98%), heel pad (I2 76%) and intrinsic muscles (I2 91%, 81%). Extensor digitorum brevis (EDB) ultrasound measures were significantly thinner in diabetics for all dimension measures compared to healthy controls except one study, which reported no significant differences in EDB thickness.

CONCLUSIONS:
No direct evidence was found to indicate B-mode ultrasound measures can predict soft tissue changes in the plantar foot in diabetes, although low level studies indicate ultrasound has the potential to identify structural change. Clinical, methodological and statistical heterogeneity limit result applicability. This review highlights the need for robust prospective longitudinal research to examine the predictive validity of this method.
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NewsBot · Feb 10, 2020

Prevalence of denervation in the intrinsic foot muscles in patients with distal predominantly small fiber neuropathy.
Parikh P, Polston D, Li Y
Muscle Nerve. 2020 Feb 7

INTRODUCTION:
We aimed to evaluate the significance of electromyographic findings in the intrinsic foot muscles (IFMs) of patients with skin biopsy proven small fiber neuropathy (SFN).

METHODS:
This was a single-center retrospective analysis of patients who underwent skin biopsy for intra-epidermal nerve fiber density (IENFD) measurement and electrodiagnostic (EDX) study for evaluation of polyneuropathy.

RESULTS:
A total of 1416 patents with normal lower extremity EDX studies proximal to the foot were included. Active denervation was seen in 16.1% of IFMs in patients with skin biopsy proven SFN and 4.1% of patients without SFN (p<0.0001). Reinnervation changes without active denervation were observed in 30.4% of SFN patients and 23.8% of patients without SFN (p=0.01). IENFD was lower in SFN patients with active denervation in IFMs than without (p<0.0001).

DISCUSSION:
Evaluation of active denervation in the IFMs can reveal large fiber dysfunction in SFN patients with otherwise normal routine EDX findings.
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NewsBot · Feb 21, 2022

Validity of ultrasound imaging for intrinsic foot muscle cross-sectional area measurements demonstrated by strong agreement with MRI
Dallin C Swanson, Joshua K Sponbeck, Derek A Swanson, Conner D Stevens, Steven P. Allen, Ulrike H. Mitchell, James D. George & Aaron Wayne Johnson
BMC Musculoskeletal Disorders volume 23, Article number: 146 (2022)

Purpose
Intrinsic foot muscles maintain foot structural integrity and contribute to functional movement, posture and balance. Thus, assessing intrinsic foot muscle size and strength are important. Magnetic resonance imaging (MRI) has been shown to accurately image the individual muscles but is costly and time consuming. Ultrasound (US) imaging may provide an alternative that is less costly and more readily available. The purpose of this study was to investigate the validity and intratester reliability of US imaging in measuring intrinsic foot muscle size in comparison to MRI.

Methods
US and MRI were employed to measure the intrinsic foot muscle size involving 35 participants (females = 13; males = 22). The scanned intrinsic foot muscles included the flexor hallucis brevis (FHB), abductor hallucis (ABDH), flexor digitorum brevis (FDB), quadratus plantae (QP) and abductor digiti minimi (ADM). Pearson product correlation (r), intraclass correlation coefficients (ICC), standard error of the measurement (SEm) and minimal detectable difference (MDD) were calculated.

Results
High correlations were detected between the US and MRI cross-sectional area (CSA) measurements (r = .971 to 0.995). Test reliability was excellent for both MRI and US (ICC = 0.994 to 0.999). Limits of agreement between MRI and US measurements from ranged from 5.7 to 12.2% of muscle size. SEm values for US ranged from 0.026 to 0.044 cm2, while the SEm for MRI ranged from 0.018 to 0.023 cm2. MDD values for US ranged from 0.073 to 0.122 cm2, while MRI ranged from 0.045 to 0.064 cm2.

Conclusions
US appears to be a valid and reliable alternative to MRI when measuring intrinsic foot muscle CSA. While US is less costly and more readily available, the MRI results were shown to be slightly more precise.
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NewsBot · Aug 9, 2022

A systematic review on foot muscle atrophy in patients with diabetes mellitus
Neerja Thukral, Jaspreet Kaur & Manoj Malik
International Journal of Diabetes in Developing Countries (2022)

Introduction
Skeletal muscles respond heterogenically under various stresses and conditions like diabetes mellitus and cancer. Various imaging techniques like radiographs, ultrasonography, and MRI have been used to find out the muscle mass and cross-sectional area of foot muscles.

Objective
To summarize the findings of various imaging techniques to draw inference of presence of foot muscle atrophy in diabetic patients.

Methodology
Articles from databases-PubMed, Science Direct, Taylor & Francis, and Springer Link were retrieved.

Results
The imaging techniques confirm the presence of atrophy of foot muscles.

Conclusion
Based on the findings of study, it can be concluded that foot muscle atrophy is present in diabetics, with intrinsic muscles affected first in terms of decreased cross-sectional area, reduced plantar tissue and skin thickness, and a decrease in total foot muscle volume.
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