Prevalence of diabetic cheiroarthropathy and its association with macrovascular complications: A cross‐sectional study

Diabetes mellitus (DM) patients have a higher incidence of musculoskeletal issues compared to those without diabetes. With diabetes-related complications increasing, early detection of musculoskeletal diseases is crucial for better quality of life and reduced morbidity. Limited joint mobility (LJM), also known as diabetic stiff hand or diabetic cheiroarthropathy (DCA), is an often overlooked complication of type 2 DM. It manifests as painless stiffness in hands, restricted joint movement, and tight skin. Contractures in hand joints can spread to major joints like elbows and knees, severely impacting daily tasks and quality of life. Physical examination aids in diagnosing LJM and related rheumatic conditions like scleroderma. The cause of DCA is unclear, but it involves nonenzymatic glycation of collagen, resulting in excess crosslinking and stiffening of joints. Diagnosis includes the "prayer sign" and "tabletop test." Studies link long-term diabetes and microvascular complications with LJM Syndrome. Cheiroarthropathy correlates with cardiovascular and cerebrovascular diseases. Hence, in this study, we undertook an assessment of the prevalence of cheiroarthropathy in type 2 DM patients with a view to determine its potential as a diagnostic marker for diabetic macrovascular complications. Therefore, an evaluation of DCA in individuals with DM across diverse age groups and varying duration of DM constituted the primary objective of this research endeavor. In the study on DCA, 251 type 2 DM patients aged 18–65 years were screened from inpatients and outpatients of SRM Medical College Hospital and Research Centre between February 2021 and July 2022. The SRM Institutional Ethical Committee approved the study (No. 2355/IEC/2021). Patients with certain conditions were excluded, and written informed consent was obtained. Before physical examination, data on patients' demographics, diabetes duration, treatment, and complications were collected. Weight, height, and body mass index were measured. Patients were taught the prayer sign and tabletop sign to assess DCA. Failure to touch fingers in the prayer stance or flatten the hand on a tabletop indicated LJM. Positive cases underwent further testing for rheumatoid arthritis and systemic sclerosis. The remaining patients were diagnosed with DCA. This comprehensive approach ensures accurate diagnosis and understanding of the condition's prevalence and impact in the study population. Data were presented as mean ± standard deviation, frequency, and percentage. The Pearson chi-square test compared categorical variables. The data were analyzed using IBM SPSS, version 21.0 (IBM Corp.). The study included 251 participants meeting criteria. DCA occurred in 46 (18.3%). No significant gender difference was observed (p > 0.05). Regarding age, 24.1% of those aged 51–60 years, 35.1% over 60 years, and 10.3% aged 41–50 years had DCA. Duration of DM varied: ≤5 years (8.0%), 6–10 years (26.1%), 11–15 years (29.5%), and >15 years (14.3%). Body mass index comparison showed no significant difference (p > 0.05): obese (24.4%), overweight (19.3%), and normal weight (10.3%) (Table 1). Treatment frequency and DCA correlation was statistically insignificant (p > 0.05). Cardiovascular disease correlated positively (p < 0.05) with DCA (46.7% with, 53.3% without). Cerebrovascular accidents showed statistically significant correlation (p < 0.05): 70.0% with and 30.0% without cheiroarthropathy. These findings provide insights into demographic and clinical factors associated with DCA. Out of 251 patients, 46 (18.3%) had DCA, aligning with reported prevalence ranges of 8% to 58% influenced by population, definition, and measurement methods.1 Distinguishing DCA from other hand issues like Dupuytren's contracture is crucial. Studies show DCA prevalence between 28.5% and 29.0%, with 22.6% reported in other research.2, 3 Our study found DCA prevalence increasing with age, consistent with prior findings linking DCA to aging. Analysis revealed a significant association between diabetes duration and DCA, indicating a higher risk with longer diabetes duration. Those with prepubertal onset of diabetes exhibited more severe joint mobility limitations, attributed to hyperglycemia-induced collagen deposition during growth spurts.4 Prolonged hyperglycemia leads to nonenzymatic collagen glycation, causing resistant collagen buildup and trapping of proteins, exacerbating extracellular matrix development. Oxidative stress and hyperglycemia trigger advanced glycation end products (AGEs), generating reactive oxygen species, and inflammatory responses, further damaging cells.5 Understanding these mechanisms sheds light on DCA pathogenesis and underscores the importance of glycemic control in diabetes management. In our study, we report 46.7% DCA patients with cardiovascular diseases similar to the findings by Einarson et al. in their study of prevalence of cardiovascular disease in type 2 DM.6 Similarly on comparing cerebrovascular accidents and DCA, 15.2% patients with cerebrovascular accidents had DCA. Both the results showed an increased prevalence of atherosclerosis leading to these macrovascular complications in DCA. Elevated glucose levels drive extracellular processes, leading to protein glycation and AGEs, contributing significantly to atherosclerosis development. AGEs activate endothelium, facilitate macrophage adherence, induce pro-inflammatory cytokine release, alter low-density lipoprotein particles, and disrupt extracellular matrix, exacerbating plaque formation and inflammation. Patients with DCA were found to have a higher prevalence of atherosclerosis leading to macrovascular complications. Therefore, better glycemic control of the patient is required in the presence of diabetic cheiroarthropathy to stop the progression of the disease and further deterioration of its complications. Athul Paul: Conceptualization, methodology, data curation, writing—original draft, visualization, investigation. Kothai Gnanamoorthy: Supervision, project administration, validation; Gisha Sivan: Data curation, writing—reviewing and editing, visualization, software; Janardanan S. Kumar: Supervision, project administration, validation. The authors would like to thank the management of SRM Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Chennai, Tamil Nadu for providing facilities and encouragement. The authors declare no conflict of interest. None. All study procedures were approved by SRM Medical College Hospital and Research Centre Institutional Ethics Committee (No. 2355/IEC/2021).