Tendon changes in diabetes

NewsBot · Jul 13, 2011

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Alterations of tendons in patients with diabetes mellitus: a systematic review
R. R. de Oliveira et al
Diabet. Med. 28, 886–895 (2011)

Aims To perform a systematic review of observational studies which analyse tendon alterations in patients with diabetes mellitus compared with healthy individuals.

Methods Data collection was performed, with no language restriction, using the databases of PubMed/Medline, BIREME, CINAHL, LILACS and Cochrane, as well as the references found in these studies. Three reviewers performed independent extractions of articles. Subsequently, these reviewers analysed the articles, focusing on their methodological quality, using the appropriate scale to evaluate observational studies from the Agency for Healthcare Research and Quality.

Results Six articles were included in the analysis. Of these, four had used ultrasonographic diagnostics, one computed tomography and one magnetic resonance imaging. The patient pool comprised 396 individuals. All the articles evaluated tendon thickness and presented heterogeneous results. Two articles stated thickening or increased volume of the tendons in diabetic people, one article did not report any alteration, the fourth failed to determine any alterations and the fifth showed thinning of the tendons. The arrangement of collagen fibrils and the presence of calcification were analysed in only one article (n = 80), showing that 88.10% (n = 68) of individuals with diabetes presented disorientation of collagen fibril arrangement, while only 10% (n = 1) of healthy individuals presented this condition. Regarding tendon calcification, the article showed diabetic individuals with higher values than healthy individuals.

Conclusions All the articles indicated some relation between diabetes mellitus and tendon alterations in human beings, but due to methodological drawbacks, this association could not be sustained.
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NewsBot · Aug 17, 2013

Revisiting Physical Examination: Abadie's Sign and Achilles Intratendinous Changes in Subjects with Diabetes
Abate M. · Schiavone C. · Salini V. · Andia I
Med Princ Pract; in press

Objective: The aim of this study was to evaluate whether or not the positivity of Abadie's sign could be an indicator of asymptomatic Achilles intratendinous changes.

Subjects and Methods: A total of 18 patients (36 tendons) suffering from diabetes, with at least 1 Achilles tendon positive to Abadie's sign, were compared to matched subjects with diabetes bilaterally negative to Abadie's sign. Anthropometric measures and the Toronto Clinical Neuropathy Score were registered. Echotexture was evaluated and degenerative features classified as absent, mild, moderate and severe. The frequencies of structural abnormalities, according to both Abadie's sign and the Toronto Clinical Neuropathy Score, were determined.

Results: In the first group 26 out of 36 tendons (72.2%) showed positive Abadie's sign and a significantly higher frequency of moderate and severe (65.3%) structural abnormalities compared to Achilles tendons with negative sign (4.3%; p < 0.0001). This frequency was similar to that observed in the subjects with the highest Toronto Clinical Neuropathy Score (64.2%).

Conclusions: This study showed that Abadie's sign was a useful tool for assisting in the diagnosis of asymptomatic Achilles intratendinous changes, which, when detected early, could help prevent unexpected tendon rupture. The concordance between Abadie's sign and Achilles sonographic abnormalities needs to be evaluated in a larger sample to consider it useful for practical purposes.
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NewsBot · Oct 26, 2013

Ultrasound Morphology of the Achilles in Asymptomatic Patients With and Without Diabetes
Michele Abate, Vincenzo Salini, Pierluigi Antinolfi, Cosima Schiavone
Foot & Ankle International October 25, 2013

Background: The prevalence of tendinopathies is increased in subjects with diabetes mellitus. However, there are few data on the structural abnormalities of Achilles tendons in asymptomatic diabetic patients. The aim of the study was to assess the morphologic characteristics of the Achilles tendon in subjects with diabetes in comparison with controls without diabetes.

Methods: Participants were consecutively recruited from an outpatient population. Ultrasound longitudinal and transverse scans were performed bilaterally along the full length of Achilles tendon from the musculotendinous junction to the insertion. Degenerative features (abnormal fibrillar pattern, hypo-hyperechoic areas), signs of enthesopathy (bony erosion, enthesophytes, and bursitis), and intratendinous neovessel formation were recorded.

Results: Asymptomatic sonographic abnormalities (ASA) were significantly increased in subjects with diabetes (35/136 [25.7%] vs 32/273 [11.7%], P = .0003). Sixty tendons with ASA were observed in the first group and 45 in the latter because ASA were bilateral in 25 and in 13 subjects, respectively. ASA were more frequently localized at the enthesis (32/60 [53.3%] vs 9/45 [20%], P = .0005) in the diabetes group, whereas, on the contrary, they were more prevalent at the midportion in controls (38/45 [84.4%] vs 36/60 [60%], P < .006).

Conclusion: Diabetes may predispose to Achilles tendinopathy and particularly to Achilles enthesopathy. Longitudinal studies, evaluating the progression of the lesions not only in the midportion of the tendon but also at the insertion are needed to support this conclusion.
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NewsBot · Oct 29, 2013

Incidence and predictors of hospitalization for tendon rupture in Type 2 diabetes: the Fremantle Diabetes Study
M. H. B. Zakaria, W. A. Davis, T. M. E. Davis
Diabetic Medicine; Accepted Article

Aims
To determine the incidence and predictors of tendon ruptures requiring hospitalization of representative patients with Type 2 diabetes.

Methods
A total of 1296 patients from the longitudinal observational Fremantle Diabetes Study, Phase I, and 5159 de-identified age- and sex-matched control subjects without diabetes from the same urban area were studied. The patients’ mean (sd) age was 64.0 (11.3) years and 48.6% of them were male. Their median (interquartile range) diabetes duration was 4.0 (1.0–9.0) years. The main outcome assessed was any tendon rupture requiring hospitalization in the Fremantle Diabetes Study subjects and the matched control subjects. Independent predictors of spontaneous ruptures in the patients from the Fremantle Diabetes Study were assessed using Cox proportional hazards modelling.

Results
The incidence rate ratio for any tendon rupture requiring hospitalization in patients vs control subjects was 1.44 (range 1.10–1.87; P=0.005). Independent predictors of spontaneous ruptures in patients were BMI [hazard ratio 1.05 (95% CI 1.002–1.10] for 1 kg/m2 increase; P=0.010] and alcohol consumption [hazard ratio 1.52 (95% CI 1.11–2.09) for √1 standard drink/day increase; P=0.010]. Adjustment of the incidence rate ratio for overall rupture requiring hospitalization for these variables using the BMI and alcohol consumption data of the contemporary general population suggested it could be as high as 1.84.

Conclusions
There is a greater risk of tendon rupture requiring hospitalization in people with Type 2 diabetes. Alcohol consumption and adiposity are potentially modifiable risk factors of spontaneous ruptures in patients with diabetes.
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NewsBot · Jun 5, 2014

Histological and Biomechanical Analysis of the Effects of Streptozotocin- induced Type One Diabetes Mellitus on Healing of Tentomized Achilles Tendons in Rats
Zhaleh Mohsenifar et al
Foot and Ankle Surgery; Available online 4 June 2014

Background
Tendon healing is impaired in patient with diabetes mellitus. The effects of streptozotocin-induced type 1 diabetes (STZ-D) on the healing of the transected Achilles tendon in rats was studied.

Methods
In the experimental group, type one diabetes was induced via administration of STZ. The right Achilles tendon of all the rats was transected 30 days after the STZ administration. The Achilles tendons were examined for biomechanical and histological examinations.

Results
The Statistical analysis showed that Young‘s modulus of elasticity and stress tensile load of the control group were significantly higher than those of the experimental group, and inflammation in the experimental group was significantly higher than that in the control group .At the same time, fibrosis in the experimental group was significantly lower than that of the control group.

Conclusion
Induction of type 1 diabetes by STZ significantly delayed the healing of the transected Achilles tendon in rats.
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NewsBot · Jan 13, 2015

Achilles tendons in people with type 2 diabetes show mildly compromised structure: an ultrasound tissue characterisation study
Suzan de Jonge et al
Br J Sports Med doi:10.1136/bjsports-2014-093696

Background Musculotendinous overuse injuries are prevalent in people with type 2 diabetes. Non-enzymatic glycosylation of collagen resulting in tendon stiffening may play a role. In this case–control study we determined whether patients with diabetes had poorer ultrasonographic structure in their Achilles tendons compared to age-matched controls.

Methods People with type 1 diabetes or type 2 diabetes, and age-matched controls, had computerised ultrasound tissue characterisation of both Achilles tendons. In contiguous ultrasonographic images of the tendon, echopatterns were quantified and categorised into four echo-types. Tendon abnormality was quantified as sum of echo-types III+IV. Furthermore, skin autofluorescence (AF) of the forearm (AF-value) was gathered.

Results Twenty four type 2 diabetes patients, 24 controls, 24 type 1 diabetes patients and 20 controls were included. AF-value was higher in type 1 diabetes (1.55±0.17) than in their controls (1.39±0.18, p<0.001) and in type 2 diabetes (2.28±0.38) compared to their controls (1.84±0.32, p<0.001) Achilles tendons of type 2 diabetes patients contained more echo-types III+IV (14.1±7.9%) than matched controls (8.0±5.4%, p<0.001). There was a trend towards a difference in echo-types III+IV between type 1 diabetes patients (9.5±5.3%) and their controls (6.5±3.7%, p=0.055). In a stepwise linear regression analysis, body mass index (BMI) was moderately associated with tendon abnormality in patients with diabetes and controls (β=0.393, p<0.001).

Conclusions Type 2, and possibly type 1, diabetes patients showed poorer ultrasonographic Achilles tendon structure that may be a risk factor for tendinopathy. Although markers for accumulation of advanced glycation end products were elevated in both diabetes populations, only BMI was associated with these abnormalities.
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NewsBot · May 12, 2015

Alterations of tendons in diabetes mellitus: what are the current findings?
Liu Shi, Yun-feng Rui, Gang Li, Chen Wang
International Orthopaedics; May 2015

As a connective tissue, tendon connects the muscle and bone, and plays the key role in the locomotor system. Some previous studies have shown the pathological alternations in diabetic tendons, which might result in the structural and functional changes, and even accelerate the process of diabetic foot. In this review, we examined the current findings of the diabetic tendons in the form of various aspects, and summarized the clinical presentation, imaging, biomechanical, histopathological, cellular and molecular abnormalities in the diabetic tendons. The progress of diabetic tendon damage is complicated and the main hypotheses include the excessive accumulation of AGEs, the altered inflammatory response, neovascularization and insensitive neuropathy. However, the cellular and molecular mechanisms of these alterations are still ambiguous. Tendon stem/progenitor cells (TSPCs) have been discovered to play important roles in both tendon physiology and tendon pathology. Recently, we identified TSPCs from patellar tendons in our well-established diabetic rat model and found impaired tenogenic differentiation potential of these cells. We proposed a new hypothesis that the impaired cell functions of diabetic TSPCs might be the underlying cellular and molecular mechanism of the diabetic tendon alternations. These findings should be helpful to establish a better therapeutic strategy for diabetic tendon repair and regeneration.
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NewsBot · Jun 14, 2015

Achilles tendinopathy in elderly subjects with type II diabetes: the role of sport activities
Michele Abate, Vincenzo Salini, Cosima Schiavone
Aging Clinical and Experimental Research; June 2015

Background
Exercise is an important therapeutic tool in the management of diabetes in older people. Aim of this study was to assess the relationship among type II diabetes, sport, overweight, and symptomatic Achilles tendinopathy in elderly subjects.
Methods
Thirty-eight patients suffering from Achilles tendinopathy and thirty-eight controls were enrolled. The prevalence of diabetes and sport practice as well as BMI and Glycated Hemoglobin (HbA1c) values were registered. An ultrasound evaluation of Achilles tendon was performed.
Results
Patients showed an increased prevalence of diabetes (42 vs. 13.1 %, p = 0.004), and practice of sport (60.5 vs. 28.9 %, p = 0.0001), and higher BMI values (26.8 ± 3 vs. 24.8 ± 2.3, p = 0.001). Sonographic abnormalities, being diagnostic criteria, were present in all the patients with Achilles tendinopathy, but signs of degeneration were also found in 36.8 % of asymptomatic controls. Symptomatic subjects with diabetes, compared to those without, showed a higher prevalence of severe degeneration (75 vs. 36.3 %, p = 0.01). HbA1c values were significantly lower in sport practitioners, both diabetics and non-diabetics. Moreover, patients practicing sport showed a trend towards lower BMI values, compared to the sedentary counterpart.
Conclusions
Sport practice in elderly diabetics provides relevant metabolic advantages, reducing HbA1c and BMI. However, some sport activities (e.g., speed walking, jogging or tennis) can expose to the risk of Achilles tendinopathy. So, sport practice should be encouraged, but practitioners should follow individual training programs and be submitted to periodic sonographic controls.
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NewsBot · Nov 7, 2015

Human Achilles tendon glycation and function in diabetes.
Couppe C et al
J Appl Physiol (1985). 2015 Nov 5:jap.00547.2015

Diabetic patients have an increased risk of foot ulcers, and glycation of collagen may increase tissue stiffness. We hypothesized that the level of glycemic control (glycation) may affect Achilles tendon stiffness, which can influence gait pattern. We therefore investigated the relationship between collagen glycation, Achilles tendon stiffness parameters and plantar pressure in poorly (n = 22) and well (n = 22) controlled diabetic patients, including healthy age matched (45-70 yrs) controls (n = 11). There were no differences in any of outcome parameters (collagen cross-linking or tendon stiffness) between patients with well-controlled and poorly controlled diabetes. The overall effect of diabetes was explored by collapsing the diabetes groups (DB) compared to the controls. Skin collagen cross-linking lysylpyridinoline (LP), hydroxylysylpyridinoline (HP), (136%, 80%, P < 0.01) and pentosidine concentrations (55%, P < 0.05) were markedly greater in DB. Furthermore, Achilles tendon material stiffness was higher in DB (54%, P < 0.01). Notably, DB also demonstrated higher forefoot/ rearfoot peak plantar pressure (PPP)-ratio (33%, P < 0.01). Overall, Achilles tendon material stiffness and skin connective tissue cross-linking were greater in diabetic patients compared to controls. The higher foot pressure indicates that material stiffness of tendon and other tissue (e.g skin and joint capsule) may influence on foot gait. The difference in foot pressure distribution may contribute to the development of foot ulcers in diabetic patients.
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NewsBot · Nov 12, 2015

Does type 1 diabetes mellitus affect Achilles tendon response to a 10 km run? A case control study
Andrea M. Y. Wong, Sean I. Docking, Jill L. Cook and James E. Gaida
BMC Musculoskeletal Disorders 2015, 16:345 doi:10.1186/s12891-015-0803-z

Background
Achilles tendon structure deteriorates 2-days after maximal loading in elite athletes. The load-response behaviour of tendons may be altered in type 1 diabetes mellitus (T1DM) as hyperglycaemia accelerates collagen cross-linking. This study compared Achilles tendon load-response in participants with T1DM and controls.

Methods
Achilles tendon structure was quantified at day-0, day-2 and day-4 after a 10 km run. Ultrasound tissue characterisation (UTC) measures tendon structural integrity by classifying pixels as echo-type I, II, III or IV. Echo-type I has the most aligned collagen fibrils and IV has the least.

Results
Participants were 7 individuals with T1DM and 10 controls. All regularly ran distances greater than 5 km and VISA-A scores indicated good tendon function (T1DM = 94 ? 11, control = 94 ? 10). There were no diabetic complications and HbA1c was 8.7 ? 2.6 mmol/mol for T1DM and 5.3 ? 0.4 mmol/mol for control groups. Baseline tendon structure was similar in T1DM and control groups – UTC echo-types (I-IV) and anterior-posterior thickness were all p > 0.05. No response to load was seen in either T1DM or control group over the 4-days post exercise.

Conclusion
Active individuals with T1DM do not have a heightened Achilles tendon response to load, which suggests no increased risk of tendon injury. We cannot extrapolate these findings to sedentary individuals with T1DM.
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NewsBot · Nov 23, 2015

Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis
Tom A Ranger et al
Br J Sports Med doi:10.1136/bjsports-2015-094735

Abstract
Background Musculoskeletal symptoms limit adherence to exercise interventions for individuals with type 2 diabetes. People with diabetes may be susceptible to tendinopathy due to chronically elevated blood glucose levels. Therefore, we aimed to investigate this potential association by systematically reviewing and meta-analysing case–control, cross-sectional, and studies that considered both of these conditions.

Methods Nine medical databases and hand searching methods were used without year limits to identify all relevant English language articles that considered diabetes and tendinopathy. Two authors applied exclusion criteria and one author extracted data with verification by a second author. Meta-analysis was conducted using a random effects model. Results were expressed as odds ratio (OR), mean difference or standardised mean difference with a confidence intervals (95% CI). Heterogeneity was assessed by I2.

Findings 31 studies were included in the final analysis of which 26 recruited people with diabetes and five recruited people with tendinopathy. Tendinopathy was more prevalent in people with diabetes (17 studies, OR 3?67, 95% CI 2?71 to 4?97), diabetes was more prevalent in people with tendinopathy (5 studies, OR 1?28, 95% CI 1?10 to 1?49), people with diabetes and tendinopathy had a longer duration of diabetes than people with diabetes only (6 studies, mean difference 5?26 years, 95% CI 4?15 to 6?36) and people with diabetes had thicker tendons than controls (9 studies, standardised mean difference 0?79 95% CI 0?47 to 1?12).

Interpretation These findings provide strong evidence that diabetes is associated with higher risk of tendinopathy. This is clinically relevant as tendinopathy may affect adherence to exercise interventions for diabetes.
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NewsBot · Feb 24, 2016

Achilles or biceps tendon rupture in women and men with type 2 diabetes
A population-based case-control study
Julia Spoendlin, Christian Meier, Susan S. Jick, Christoph R. Meier
Journal of Diabetes and its Complications;Article in Press

Aims
Previous studies suggest that diabetes causes alterations in tendon collagen structure, but evidence on how such findings translate into clinical practice is scarce. We aimed to analyze the association between type 2 diabetes and the risk of tendon rupture.

Materials and Methods
We conducted a matched case-control analysis using the UK-based Clinical Practice Research Datalink. Cases (n=7895) were aged 30-89 years and had an incident diagnosis of Achilles- or biceps tendon rupture between 1995 and 2013. In multivariable logistic regression analyses we compared the odds of tendon rupture between patients with or without type 2 diabetes, in men and women separately, and taking into account diabetes severity (HbA1c), duration, and antidiabetic drug treatment.

Results
Within 165 (7.1%) female cases with type 2 diabetes, odds ratios (ORs) were increased with poorer diabetes control (OR 2.03, 95% CI 1.20-3.41, HbA1c ≥9% [≥75mmol/mol]), longer disease duration (OR 1.60, 95% CI 0.93-2.74, ≥10 years), and current insulin use (OR 2.25, 95% CI 1.30-3.90, ≥20 prescriptions). Among 372 (6.7%) male cases, there was no effect of type 2 diabetes on the risk of tendon rupture.

Conclusions
Our results suggest that the risk of tendon ruptures may be increased in women with poorly controlled type 2 diabetes, but not in men.
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NewsBot · Aug 23, 2016

Rehabilitation of Tendon Problems in Patients with Diabetes Mellitus
Jonathan Rees, Jamie E. Gaida, Karin Gr?vare Silbernagel, Johannes Zwerver, Joseph S. Anthony, Alex Scott
Metabolic Influences on Risk for Tendon Disorders
Volume 920 of the series Advances in Experimental Medicine and Biology pp 199-208
D

Exercise is crucial in the management of diabetes mellitus and its associated complications. However, individuals with diabetes have a heightened risk of musculoskeletal problems, including tendon pathologies. Diabetes has a significant impact on the function of tendons due to the accumulation of advanced glycation end-products in the load-bearing collagen. In addition, tendon vascularity and healing may be reduced due to diabetes-induced changes in the peripheral vascular system, and impaired synthesis of collagen and glycosaminoglycan. The current chapter presents an evidence-based discussion of considerations for the rehabilitation of tendon problems in people with diabetes. The following conditions are discussed in detail ? calcific tendinopathy, tenosynovitis, tendon rupture, and non-calcifying tendinopathy. Common diabetes-related findings are presented, along with their potential impact on tendinopathy management and suggested modifications to standard tendinopathy treatment protocols. A holistic approach should be used to optimize musculotendinous function, including a comprehensive exercise prescription addressing strength, flexibility, and aerobic fitness.
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NewsBot · Oct 11, 2016

High Prevalence of Achilles Tendon Enthesopathic Changes in Patients with Type 2 Diabetes Without Peripheral Neuropathy.
High Prevalence of Achilles Tendon Enthesopathic Changes in Patients with Type 2 Diabetes Without Peripheral Neuropathy
Journal of the American Podiatric Medical Association In-Press.

Abstract
Background: Metabolic disorders are known to alter the mechanical properties of tendons. We sought to evaluate the prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with type 2 diabetes mellitus (T2DM) without peripheral neuropathy.

Methods: We recruited 43 patients with T2DM and 40 controls. Neuropathy was excluded with the Michigan Neuropathy Scoring Instrument. Bilateral ultrasonography of the Achilles tendon enthesis was performed.

Results: Patients with T2DM had a higher prevalence of hypoechogenicity (26.7% versus 2.5%; P = .0001), entheseal thickening (24.4% versus 8.7%; P = .007), and enthesophytes (74.4% versus 57.5%; P = .02). No differences were found in the number of patients with erosions (1.2% versus 0%; P > .99), cortical irregularities (11.6% versus 3.7%; P = .09), bursitis (5.8% versus 3.7%; P = .72), or tears (2.3% versus 1.2%; P > .99). The mean ± SD sum of abnormalities was higher in patients with T2DM (1.5 ± 1.1 versus 0.7 ± 0.6; P < .0001), as was the percentage of bilateral involvement (72.1% versus 45.0%; P = .01). Mean ± SD thickness did not differ between patients and controls (4.4 ± 1.1 mm versus 4.2 ± 0.8 mm; P = .07).

Conclusions: According to our data, there is an elevated prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with T2DM independent of peripheral neuropathy.
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NewsBot · Nov 4, 2018

Sonographic evaluation of the achilles tendon and plantar fascia of type 2 diabetics in Nigeria
Babalola Ishmael Afolabine et al
Source

Background: The aim of this study is to compare the Achilles tendon (AT) thickness (ATT) and plantar fascia (PF) thickness (PFT) of diabetics with and without peripheral neuropathy (PN) to that of a control population. Materials and Methods: B-mode sonography of the AT and PF was done. Correlation analysis was used to determine the relationship between ATT and PFT with demographic data such as body mass index, duration of diabetes, and presence of PN. A multivariate regression was used to construct models for determining the thicknesses. Results: Eighty type 2 diabetics were recruited and categorized into groups based on the presence or absence of PN (Groups A and B, respectively). Group A constituted 57 participants while there were 23 in Group B. Eighty controls constituted Group C. Mean values of 6.08 ± 0.65, 5.08 ± 0.48, and 4.57 ± 0.57 mm (P < 0.001) of the right ATT were obtained in Groups A to C while values of 1.95 ± 0.35, 1.88 ± 0.39, and 1.44 ± 0.20 mm (P < 0.001) were obtained for the right PFT. Conclusion: The presence of PN and factors such as diabetes duration can affect the thickness of AT and PF.
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NewsBot · Nov 17, 2019

Relationships between cardiovascular disease risk
factors and Achilles tendon structural and mechanical
properties in people with Type 2 Diabetes
B.K. Coombes et al
Nr 2019;9 (3):395-404

Background. Patients with diabetes have 44% greater risk of tendon rupture requiring hospitalisation. Despite this, in vivo research of the associations of diabetes and
other cardiovascular disease risk factors on structural and mechanical properties of
the Achilles tendon are sparsely studied.
Methods. Inactive individuals with type 2 diabetes (n=33) underwent ultrasound and
shear wave elastography imaging of their Achilles tendons bilaterally to measure thickness and shear wave velocity (SWV), an index of tendon elastic modulus. In a separate
session, participants underwent assessment of body composition, cardiorespiratory
fitness and blood biomarkers. Seven inactive individuals without type 2 diabetes were
recruited for comparison of tendon structural and mechanical properties.
Results. In participants with diabetes, free tendon SWV displayed large negative correlations with hip circumference (r=-0.67, P <0.001), waist circumference
(r=-0.59, P <0.001) and body mass index (r=-0.52, P <0001), and a moderate positive
correlation with VO2
peak (r=0.34, P =0.006). SWV was lower in participants with
diabetes taking statins compared to not taking statins (Free tendon: median difference 8%, P=0.004); insertion: 11%, P =0.001). Compared to the control group, the
diabetes group had thicker Achilles free tendon (median difference 15%, P<0.001)
and Achilles insertion (17%, P=0.006), but no differences in SWV (P=0.490 or 0.577
respectively).
Conclusions. Achilles tendons from individuals with type 2 diabetes were thicker compared to inactive individuals without diabetes. Adiposity, statin use and low
cardiorespiratory fitness were associated with inferior Achilles tendon mechanical
properties in people with diabetes.
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NewsBot · Feb 18, 2021

Achilles tendon degeneration on ultrasound in type 2 diabetic patients
Babalola Ishamel Afolabi et al
J Ultrason. 2021; 20(83): e291–e299.

Aim of study
The main goal of this study was to compare the various degenerative changes in the Achilles tendon of type 2 diabetic patients to that of controls. The influence of diabetic peripheral neuropathy, duration of diabetes mellitus, age, and body mass index on the occurrence of degenerative changes was also evaluated.

Materials and methods
The Achilles tendons of both limbs were evaluated with high-resolution ultrasound in 80 type 2 diabetics and 80 age/sex-matched controls. A 10 g Semmes Weinstein monofilament was used to examine for peripheral neuropathy. Anthropometric measurements and biochemical assessment of glycemic control (fasting plasma glucose and glycated hemoglobin) were also done.

Results
The mean age of type 2 diabetic subjects and healthy controls was 60.9 ± 10.3 years (range 41–79 years) and 61.0 ± 10.3 years (range 40–79 years), respectively (p = 0.963). The median duration of diabetes mellitus was 42.0 months (range = 1–456 months). The prevalence of degenerative changes (calcifications, disorganized fibers and/or hypoechoic foci) was significantly higher in type 2 diabetic subjects than controls in both the right (55.0% vs. 18.8%, p <0.001) and left (52.5% vs. 18.8%, p <0.001) feet.

Conclusion
The Achilles tendons of type 2 diabetic subjects have significantly more degenerative changes than their age/ sex-matched controls in our locality. Disorganized Achilles tendon fibers occur significantly more often among male than female type 2 diabetic subjects. Disorganization of Achilles tendon fibers and hypoechoic foci are significantly more prevalent in type 2 diabetic subjects with peripheral neuropathy than those without peripheral neuropathy. Body mass index did not affect the occurrence of degenerative changes in the Achilles tendon of participants.
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NewsBot · May 8, 2022

Is Elevated Hba1c Level Associated with Achilles Tendon Contracture Development in Diabetic Foot Patients?
R A Primadhi, H N Rasyid
Malays Orthop J. 2022 Mar;16(1):70-75

Introduction: Chronic hyperglycemia can increase extracellular matrix (ECM) accumulation that leads to tendon fibrosis and subsequent contracture. Considering the reversibility of fibrosis, it is important to identify factors that are associated with it. The purpose of this study was to determine whether elevated HbA1c levels are associated with the development of Achilles tendon contracture in diabetes mellitus patients.

Materials and methods: We reviewed 206 patients with diabetic foot problems between January 2015-December 2019. Demographic data, the presence of Achilles tendon contracture, and laboratory results were documented and statistically analysed between patients with contracture and without contracture.

Results: Patients' mean age was 58.46 ± 6.67 years old. Contracture was found in 84 out of 206 patients (40.78%) patients, with female predominance (45/84 patients; 53%). While contracture was found significantly associated with sex difference (0.035) and age groups (p=0.006), there was no meaningful association with HbA1c level groups (p=0.324).

Conclusion: Findings do not support the use of HbA1c level as a sole determinant of Achilles tendon contracture. Seemingly, there are other confounding factors affecting the Achilles tendon contracture development in diabetes mellitus patients. It should be emphasised that albeit the association between chronic hyperglycemia and contracture development, the low HbA1c should not be overlooked as having no risk of Achilles tendon contracture and vice versa.
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NewsBot · Jun 2, 2022

Effect of Diabetes on Tendon Structure and Function: Not Limited to Collagen Crosslinking
Rachana Vaidya et al
J Diabetes Sci Technol. 2022 Jun 2

Diabetes mellitus (DM) is associated with musculoskeletal complications-including tendon dysfunction and injury. Patients with DM show altered foot and ankle mechanics that have been attributed to tendon dysfunction as well as impaired recovery post-tendon injury. Despite the problem of DM-related tendon complications, treatment guidelines specific to this population of individuals are lacking. DM impairs tendon structure, function, and healing capacity in tendons throughout the body, but the Achilles tendon is of particular concern and most studied in the diabetic foot. At macroscopic levels, asymptomatic, diabetic Achilles tendons may show morphological abnormalities such as thickening, collagen disorganization, and/or calcific changes at the tendon enthesis. At smaller length scales, DM affects collagen sliding and discrete plasticity due to glycation of collagen. However, how these alterations translate to mechanical deficits observed at larger length scales is an area of continued investigation. In addition to dysfunction of the extracellular matrix, tendon cells such as tenocytes and tendon stem/progenitor cells show significant abnormalities in proliferation, apoptosis, and remodeling capacity in the presence of hyperglycemia and advanced glycation end-products, thus contributing to the disruption of tendon homeostasis and healing. Improving our understanding of the effects of DM on tendons-from molecular pathways to patients-will progress toward targeted therapies in this group at high risk of foot and ankle morbidity.
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NewsBot · Oct 4, 2022

Characterizing conventional ankle MRI findings of nerve and muscle changes in diabetic patients: a case-control study
Brian Lue et al
Skeletal Radiol. 2022 Sep 28.

Background: Foot and ankle amputation is a feared complication of diabetic neuropathy and diabetes mellitus (DM) accounts for 80% of all in-hospital amputations. Magnetic resonance neurography is an effective tool in characterizing neuromuscular sequelae of the disease. However, conventional ankle MRI is more commonly performed and has not been studied to assess neuromuscular changes of DM.

Objective: The objective is to characterize neuromuscular changes of diabetic patients in a case-control study using conventional ankle MRI.

Methods: Between November 2019 and July 2021, 110 consecutive ankle MRI scans (n = 102 patients) at our county hospital were reviewed and met the inclusion criteria. Patients were divided into two cohorts, diabetic (N = 63) and non-diabetic (N = 39). Demographics, HgbA1c, and reason for MRI study were collected via retrospective chart review. The presence of intramuscular edema-like signal, pattern of the edema, muscle fatty infiltration, and measurements of the cross-sectional area of the posterior, medial, and lateral tibial nerves (PTN, MPN, and LPN) was recorded blinded to the clinical findings by two readers.

Results: Muscle edema-like signal was much more likely to be found in DM (odds ratio 19.5, 95% CI 7.0-54.6, p < 0.001). DM also showed increase of 0.87 in the mean grade of muscle fatty infiltration (p < 0.001). There were higher rates of nerve T2 hyperintensity (odds ratio 14.0, 95% CI 3.1-62.7, p < 0.001) and the measured areas of the PTN, MPN, and LPN were also larger in DM compared to their non-diabetic counterparts (PTN: 0.16 cm2 vs. 0.10 cm2, p < 0.01; MPN: 0.09 cm2 vs. 0.05 cm2, p < 0.01; LPN: 0.07 cm2 vs. 0.04 cm2, p < 0.05).

Conclusion: Conventional ankle MRIs can be used to detect DM-related neuromuscular changes.
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NewsBot · Oct 25, 2023

Diabetes mellitus-related musculoskeletal disorders: Unveiling the cluster of diseases
Viktória Csonka et al
Primary Care Diabetes 27 August 2023

Highlights
•Eight out of ten Type-2 Diabetes Mellitus (T2DM) patients likely suffer from musculoskeletal complications.
•Similar factors play a pivotal role in the development of both internal organs and musculoskeletal complications of DM.
•Many musculoskeletal manifestations of DM can be diagnosed by physical examination and their presence are indicative of DM.
•Early recognition and management of musculoskeletal abnormalities have become important aspects in the treatment.
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The current study ushers in a comprehensive review in clinical research to demonstrate the prevalence of musculoskeletal (MSK) complications in diabetes mellitus and the most relevant clinical aspects. In particular, revealing the early symptoms of the disorders, the pathology lurking behind the complications and their optimal management. In diabetes mellitus, MSK complications are common and are largely due to similar pathogenetic factors responsible for the internal organ complications associated with diabetes leading to chronic low-intensity inflammatory processes. MSK disorders develop by vasculopathy, neuropathy, arthropathy or combinations of the above, which are not specific to diabetes. However, their prevalence is significantly increased in diabetes and contributes to the disability impairing patients' quality of life. Locomotor disease affects approximately 34.4–83.5 % of patients suffering from type-2 diabetes mellitus. Several musculoskeletal abnormalities (cheiroarthropathy, Dupuytren’s contracture, trigger finger, ect.) can be diagnosed upon physical examination, although certain symptoms (frozen shoulder, neurogenic arthropathy, septic arthritis, etc.) require differential diagnostic considerations. Early identification regarding characteristic symptoms in the treatment reducing inflammation and pain, followed with increasingly strenuous exercise therapy, aligned with optimal management of carbohydrate metabolism, proves essential in alleviating MSK complications.
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