Limited joint mobility (LJM) or diabetic cheiroarthropathy is a consequence of the advanced glycation endproducts that occur in diabetes affecting the collagen in ligaments and restricts movement of key joints in the foot that are needed for normal biomechanics. It occurs in 30-50% of adults with type 1 diabetes, but the prevalence can depend on the threshold of joint range of motion that is used as a cut-off point to define it and the population being studied. The stiff hands in diabetes was first described in 1957 by Lundbæk and it became more widely known after Rosenbloom’s publication in 1974.
Limited joint mobility can occur in both type 1 and type 2 diabetes and the risk increases with higher long-term HbA1c values and the duration of diabetes.
Typically it starts with the fifth finger in the hand and progresses to a flexion contracture of all the fingers with a shiny waxy appearance to the skin; hence the use of the term, cheiroarthropathy; cheiro- is a variant of the prefix, chiro-, meaning ‘hand’. This stiffness and flexion contraction of the fingers is also referred to as stiff hand syndrome or the prayer sign. As all joints in the body can be affected, limited joint mobility is the preferred term over diabetic cheiroarthropathy.
Cross-sectional investigations have shown a correlation between limited joint mobility and microvascular complications. Assessment of limited joint mobility could be considered as a clinical tool to help identify those at increased risk for developing the microvascular complications.
Pathogenesis:
With the hyperglycemia that occurs in diabetes, there is a nonenzymatic glycosylation of collagen resulting in abnormally cross-linked collagens which become resistant to degradation. There is also increased collagen hydration that may contribute. The shiny skin that is often observed in the hands is due to the glycation of the collagen in the skin.
Affects on the Foot:
Subtalar joint and ankle joint motion is reduced.
First MPJ motion is going to lead to hallux limitus and hallus rigidus.
LJM contributes to increased plantar pressures.
The effects of LJM in the hands may mean that self-care instructions for foot care may not be able to be complied with, so this should be checked for.
Management:
There is some suggestion that the prevalence is less now than in the past due to generally better glycaemic control. Optimization of glycaemic control is probably important to halt or slow progression.
Physical therapy.
There was a report of an improvement in LJM with an aldose reductase inhibitor (sorbinil), but this was not replicated in a subsequent study with a different drug in the same class (ponalrestat).
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