Carpal Tunnel Syndrome and Diabetes, A Challenging Problem

Approximately 20% of diabetic patients will develop carpal tunnel syndrome. Peripheral neuropathy makes the condition of the carpal tunnel worse. It is suggested that the never that already has established hypoxia caused by diabetes is more vulnerable to local compression. Other mechanisms and explanations are also involved, so it is a difficult diagnosis). Some people believe that patients with diabetic neuropathy will have a high prevalence of carpal tunnel syndrome.

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Electrodiagnostic testing (EMG and nerve studies) cannot distinguish patients with clinical carpal tunnel syndrome from patients with diabetic polyneuropathy. The decision to treat these patients should be made independently of the electrodiagnostic findings. When treating the patient, try to figure out the patient’s blood sugar level. There may be difficulty in determining if the blood sugar is under control.

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HBA1C (the glycosylated hemoglobin test) is an important blood test that shows how well the diabetes is being controlled. The test provides an average blood sugar control over the last 2-3 moths. The normal range of hemoglobin A1c is between 4% and 5.6%. When the level is 6.5% or higher, this indicated diabetes. The goal of treatment is to make sure that the patient with diabetes has hemoglobin A1c less than 7%. The higher the levels of Hemoglobin A1c, the higher the risk of developing complications. People should have the test done every three months to check and see that their blood sugar is under control. At least, the test should be done twice a year.

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The difficulty in carpal tunnel syndrome in diabetic patients is the difficulty of diagnosis, the difficulty in determining if the diabetes is being controlled or not, and if there will be surgery needed, will the patient have complications or not.

Patients who develop complications in orthopedics include: diabetics, obese patients, heavy smokers and patients taking blood thinners.

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If the condition is acute or an emergency, we have to do surgery. If the condition is elective, then surgery can wait. If the patient has poor glycemic control, then you probably don’t want to perform elective surgery on the patient such as carpal tunnel release. Remember, elective surgery can wait.

High blood sugar is linked to increased wound complications after surgery. Hemoglobin A1c is used to monitor the patient’s blood sugar level. The higher preoperative Hemoglobin A1c level, the more there is a risk factor for surgical site infection. Elective surgery can be delayed until HBA1c level becomes normal or better. Joint replacement surgery for example is delayed until HBA1c levels are less than 7%.

Since carpal tunnel syndrome is common in patients with diabetes, we need to take time to sort things out with these conditions. We need to know that the patient has better control of their diabetes. Carpal tunnel syndromes is a small surgery, but it can have catastrophic effect if we do not have a good control of the patient’s diabetes. Hemoglobin A1c will help us monitor the patient. Carpal tunnel surgery can cause complications and infection providing that high levels of HBA1c levels is a true risk factor for infection postoperatively.

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Gait

Gait is the pattern of how a person walks. We will be discussing different gait abnormalities.

Antalgic gait

Antalgic gait is a painful gait. A patient with antalgic gait does not want to spend time on the one leg due to pain. A patient wants to get their weight off the affected extremity. When pain is increased by walking, it leads to an antalgic gait (Figure 1).

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An antalgic gait can be caused by multiple factors due to pain in any part of the lower extremity. It is usually caused from hip or knee pathology or from severe disc radiation symptoms (Figure 2).

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The pain can be helped by using a cane on the opposite side of the painful extremity.

Trendelenburg gait

Trendelenburg gait is an abnormal gait that is usually found in people with weak abductor muscle of the hip which is supplied by the superior gluteal nerve. The patient cannot abduct the affected hip due weakness of the abductor muscles on the affected side. If the patient has weakness on one side of the pelvis and when the patient stands on that side, the pelvis on the contralateral side will drop. This is called Trendelenburg sign. A positive Trendelenburg sign occurs when there is dysfunction of the abductor muscles and the body is unable to maintain the center of gravity on the side of the stance leg (Figures 3, 4). The patient will show an excessive lateral lean to keep the center of the gravity over the stance leg.

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Weakness can also occur in patients with L5 radiculopathy or avulsion of the abductor muscle tendon (Figure 5) which occurs with increasing frequency after hip replacement surgery.

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The superior gluteal nerve injury is a major factyor in this gait. With bilateral weakness of the abductor muscles, the patient will have dropping of the pelvis on both sides during walking which leads to a waddling motion. This gait is seen in patients with myopathies.

Slap gait

Slap gait occurs due to weakness of the foot and ankle dorsiflexors which allows the foot slap down on the floor with each step. Slap gait is a heel gait abnormality that can be diagnosed by hearing the patient walk with a normal walking gait, the heel strikes the ground first followed by controlled relaxation of the foot and ankle dorsiflexors in order to allow the forefoot to come in contact with the ground

Steppage gait

Foot drop gait or steppage gait is due to total paralysis of the ankle and foot dorsiflexors (Figure 6). it is sometimes called neuropathic gait. A common symptom of foot drop is a high steppage gait that is often characterized by raising the thigh up in an exaggerated fashion while walking. The patient must externally rotate the leg or flex the hip or knee to raise the foot high enough to avoid dragging the toes along the ground. If the patient has foot drop then they have to have a high steppage gait or else they will trip on the foot and fall forward.

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Conditions causing foot drop include L4-L5 disc herniation, a herniated disc compressing the L5 nerve root may cause foot drop, lumbosacral plexus injury due to pelvic fracture (Figure 7), hip dislocation leading to injury of the common peroneal nerve (Figure 8) and injury to the knee as knee dislocation (Figure 9).

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Wide based gait

A wide based gait occurs due to myelopathy and neurological disorders. This gait disturbance is described as clumsy, staggering movements. It can be associated with cervical or thoracic spine pathology. Patient example of myelopathy with significant cervical spine disc compression of the spinal cord can be seen in Figure 10.

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Patient will have a slow, wide, broad based ataxic gait. The patient will have a wide stance as they try to maintain balance. There will be unsteadiness of the trunk with excessive shift in the center of the gravity.

Gluteus maximus gait

When the gluteus maximus muscle (Figure 11) is week, the trunk lurches backwards (extension of the trunk). It occurs at heel strike on the weakened side to interrupt the forward motion of the trunk. This compensates for weakness of hip extension. The function of the gluteus maximus muscle is external rotation and extension of the hip joint.

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Posterior Tibial Tendon Dysfunction

A tendon is a band of fibrous tissue that connects muscle to bone allowing the joint to bend. Tendons enable participation in physical activities such as running, jumping and other movements. The posterior tibial tendon starts in the calf and descends down the leg behind the inside of the ankle and attaches to the foot’s arch. Its function is to support the medial arch and sub-talar joint as the body passes over the foot. When the posterior tibial tendon becomes inflamed or is overstretched, the ability to support the arch is impaired resulting in flattening of the foot.

Posterior tibial tendon (Figure 1) dysfunction, as this phenomenon is called, can be attributed to several factors:

  • Tendon overuse.
  • exposing the foot to a significant load
  • Obesity
  • Hypertension
  • Trauma
  • Diabetes
  • Inflammatory diseases such as rheumatoid arthritis.

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    Figure 1

Patients with posterior tibial tendon dysfunction will often present with pain and swelling on the inside of the ankle, loss of the foot’s arch (flatfoot), tenderness over the mid-foot and an inability to stand on the toes.

To diagnose posterior tibial tendon dysfunction, physicians will likely use the “too many toes” test (Figure 2). Here, the physician measures abduction of the forefoot. If the

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Figure 2

posterior tibial tendon is damaged, the forefoot will deviate outwards in relation to the rest of the foot and will appear to have too many toes when viewed from behind. In addition to the “too many toes” test, the physician may ask patients to do a single heel rise. Here, patients are asked to stand with their hands on the wall and lift the unaffected foot off the ground and raise the toes on the affected foot. If the heel does not rotate inward, there is posterior tibial tendon dysfunction.

 

 

Posterior tibial tendon dysfunction can be classified in four stages:

 STAGE I – characterized by an inflamed posterior tibial tendon with normal strength. Upon examination, the patient will be tender to palpation but may show little or no change in the arch of the foot. While X-rays will most likely show no changes, an MRI will likely reveal mild to moderate tenosynovitis.

 STAGE II – characterized by a partially torn tendon or degenerative changes. Here, the physician will note considerable flattening of the arch without arthritic changes and will have a positive too many toes sign. X-rays will reveal abduction of the forefoot while an MRI will reveal a partial tear.

 STAGE III – characterized by severe tendon degeneration with a rupture likely. Patients with stage III posterior tibial tendon dysfunction will present with rigid flatfoot. X-rays will likely reveal abduction of the forefoot and collapse of the talo-navicular joint while an MRI will show a tear in the tendon.

 STAGE IV – is similar to stage III with the addition of an arthritic ankle joint.

Treatment for posterior tibial tendon dysfunction can range from conservative to surgical depending on how far the condition has progressed. In its early stages, physicians will often utilize rest, anti-inflammatory medications, and immobilization. If the foot fails to respond to conservative treatment or the condition has progressed too far, there are several surgical procedures that can be utilized. First, physicians may perform a tenosynovectomy. Here, the surgeon will debride and excise inflamed tissue surrounding the tendon. A second option is an osteotomy. Here, the surgeon changes the alignment of the calcaneus and may remove a portion of the bone. A third option is a tendon transfer where fibers from another tendon are used to repair the posterior tibial tendon. Finally, surgeons may fuse one or more bone together, eliminating movement in the joint through a process called arthrodesis. During this procedure, the forefoot is stabilized.