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Differential Diagnosis
Endocrine and Metabolic Signs and Symptoms
Endocrinology The study of ductless (endocrine) glands that
produce hormones Hormone production is regulated by feedback
mechanisms Works with the nervous system to regulate
metabolism, water and salt balance, blood pressure, response to stress, and sexual reproduction
Endocrine glands include pituitary, thyroid, parathyroids, adrenals, and pineal
Hypothalamus and pituitary maintains control over much of the endocrine system
Endocrine Glands
Endocrinology
Primary dysfunction (dysfunction of the gland itself)
Secondary dysfunction (dysfunction of outside stimulus to the gland)- May be iatrogenic- can be from cancer tx, or
removal of the gland Can result in an excess or insufficiency of
hormonal secretions
Endocrinology
Growth and development of many connective tissue structures are influenced and sometimes controlled by hormones and metabolic processes
Alterations in hormones and metabolic processes can produce a variety of musculoskeletal signs and symptoms
Neuromuscular Signs and Symptoms of Endocrine Dysfunction
Muscle weakness, myalgia and fatigue- Proximal weakness is usually painless and
unrelated to severity or duration of disease Carpal tunnel syndrome- Thickening of the transverse carpal ligament
- Thickening of the synovial sheath of the flexor tendons
- Gestational CTS- change in hormone levels during pregnancy give a temporary CTS
Neuromuscular Signs and Symptoms of Endocrine Dysfunction
Periarthritis – Inflammation of periarticular structures
Calcific Tendonitis Adhesive capsulitis Pseudogout Spondyloarthropathy Osteoarthritis
Signs & Symptoms of Endocrine Dysfunction
Pituitary Gland
Diabetes Insipidus – Caused by a lack of secretion of vasopressin (ADH)- Symptoms of severe water loss and
dehydration
- Associated with increased shoulder pain and adhesive capsulitis in older women
Pituitary Gland Acromegaly – Abnormal enlargement of
the bones of the extremities due to hypersecretion of growth hormone (GH)- Most often due to pituitary tumor in adults
- Face, jaw, hands and feet are most affected in adults
- Results in gigantism in children
- Common signs include osteophyte formation, stiffness of the hands, CTS, thoracic or lumbar pain
Adrenal Gland
Major contributor to body’s response to stress
Addison’s disease- decreased secretion
- Hypo secretion of the adrenal gland
- Insufficient cortisol & aldosterone production
- Increased pigmentation of skin- increased melanon
- Arthralgias, myalgias and progressive fatigue
- Tendon calcification
Adrenal Gland
Cushing’s Syndrome- Hyperfunction of the
adrenal gland
- Increased cortisol secretion
- “Moon” face
- Enlarged cervicodorsal fat pad
- Protuberant abdomen
- Muscle weakness – Level varies
- Bone pain and sometimes pathologic fractures due to decreased mineralization
- Poor wound healing
Thyroid Gland
Alterations in thyroid function produce changes in hair, nails, skin, eyes, gastrointestinal function, respiratory function, heart and blood vessels, nervous tissue, bone, and muscle
Thyroid disorders that may be of significance to PT include goiter, hyperthyroidism, hypothyroidism, and cancer
Thyroid Gland
Hyperthyroidism- Grave’s disease – common type of disorder
- Generalized elevation of body metabolism
- Common symptoms include tachycardia, fatigue and weight loss
- Commonly have painful shoulder restrictions associated with periarthritis. This may be unilateral or bilateral and can progress to frozen shoulder
Thyroid Gland
Hyperthyroidism- Proximal muscle weakness (pelvic girdle and thighs)
accompanied by muscle atrophy (myopathy) occurs in up to 70% of patients with hyperthyroidism
- Muscle strength begins to return in about 2 months with treatment
- Atrophy resolves more slowly
- Increased incidence of Myasthenia gravis
Thyroid Gland
Hypothyroidism- Generalized depression of metabolism
- Common symptoms include intolerance to cold, excessive fatigue and drowsiness, headaches, weight gain, dry skin and thin, brittle nails
- Myxedema is a characteristic sign – Causes a nonpitting, boggy edema around the eyes, hands and feet
- Flexor tenosynovitis with CTS is common- Almost always bilateral
Thyroid Gland
Hypothyroidism- Common to have crystal deposits (CPPD) of
the knee joint Combined with viscous fluid,
produces a “bulge” sign at
the knee
- Proximal muscle weakness is common and sometimes painful, but not always related to either the severity or duration of disease
Thyroid Gland
Hypothyroidism- Muscle hypertrophy is rare
- “Prolonged reflex” seen with DTRs – Slow muscle contraction and relaxation
- c/o aches and pains, cramps and stiffness
- Likely to develop Trigger Points
- Possible link to Fibromyalgia Syndrome
Parathyroid Glands
Disorders may produce periarthritis and tendonitis
Disorders can be associated with perarticular or tendinous calcification
Disorders are often seen in acute care settings and postoperatively
Parathyroid Glands
Hyperparthyroidism – Disrupts calcium, phosphate and bone metabolism- Major causes are tumors or renal failure
- Clinical signs and symptoms include proximal muscle weakness and fatigability, respiratory muscle myopathy, GI problems, pancreatitis, bone decalcification and psychotic paranoia
- Chief concern is kidney damage due to calcium deposits
Parathyroid Glands
Hyperparathyroidism- Bone erosion, resorption and destruction may
occur Most often affects the middle phalanx and clavicle Other affected areas may include the skull, wrists,
shoulders, knees and the axial skeleton
- Skeletal manifestations are more likely to include bone pain and fractures due to osteopenia, especially in the spine
Parathyroid Glands
Hypoparathyroidism – Leads to insufficient secretion of PTH- Muscle weakness and pain are the most common
symptoms
- Neuromuscular irritability may occur Muscle spasms Paresthesias Tetany Life-threatening cardiac arrhythmias
Pancreas
Dual functioning organ Endocrine gland – Secretes insulin and
glucagon Exocrine gland – Produces digestive
enzymes The most common disorder related to the
pancreas is Diabetes Mellitus
Diabetes Mellitus
Chronic disorder caused by deficient insulin or defective insulin action
Characterized by hyperglycemia (excess glucose in the blood) and disruption of the metabolism of carbs, fats and proteins
Results in vascular complications and neuropathies
Corticosteroids can contribute to hyperglycemia
Diabetes Mellitus
Stress can cause blood glucose levels to rise, resulting in an increased need for insulin- Can cause increased symptoms in patients
whose symptoms are normally well controlled
- Such stress may include surgery, trauma, pregnancy, puberty or infectious states
Diabetes Mellitus
Infection and atherosclerosis- Long-term complications of DM
- Usual causes of severe illness and death
- Atherosclerosis develops at a much earlier age and progresses much faster in diabetics
- End products may be cerebrovascular disease, coronary artery disease, renal artery stenosis and PVD
Diabetes Mellitus
Neuropathy- Most common chronic complication of DM
- Due to accumulation of sorbitol in the nerve cells
- Most common form is polyneuropathy which affects the peripheral nerves of the lower extremities
Causes burning and numbness in the feet May cause muscle weakness, atrophy and foot drop
Diabetes Mellitus
Carpal Tunnel Syndrome- 5-16% of CTS patients have DM
- DM leads to ischemia of the median nerve Charcot’s joint (Neuropathic arthropathy)- Partially due to the loss of proprioceptive
sensation characteristic of diabetic patients
- Associated with severe degenerative arthritis
Diabetes Mellitus Adhesive Capsulitis- Periarthritis is 5 times more likely to occur in
diabetics than nondiabetics
- Possibly related to fibroblast proliferation in the connective tissue structures
Amputations – Contributing factors include:- Blood vessel changes
- Sensory neuropathy
- Ulcerations
Diabetes Mellitus
Common hand symptoms/related diagnoses:- Flexor tenosynovitis----CTS- trigger finger
- Sclerodactyly- hardening and shrinking of the toes and fingers
- Dupuytren’s contracture
- RSD- complex regional pain syndrome
- Diabetic stiff hand
Diabetes Mellitus Exercise precautions- Monitor blood glucose levels before, during and after
strenuous exercise levels (safe levels are usually 100-250 mg/dl)
- Avoid high intensity exercise or exercises that increase BP with active retinopathy and nephropathy
- Avoid active exercise for 1 hour after insulin injection
- Diabetics should not exercise alone
- Activities should stop immediately if symptoms of hypoglycemia present – keep snacks on hand
Diabetes Mellitus
Precaution!!!- If any diabetic client arrives for a clinical
appointment in a confused or lethargic state or exhibiting changes in mental function, fingerstick glucose testing should be performed. Immediate physician referral is necessary.
Fluid Imbalances
Fluid deficit- Severe losses of water and/or solutes can lead to hypovolemic
shock
- May experience orthostatic hypotension in early stages Fluid excess
- Water intoxication (excess water without an excess of solutes) May occur with tumors and endocrine disorders Symptoms are largely neurological
- Edema (excess water and solutes) Commonly treated with diuretics. Check for potassium levels on
any patient taking diuretics – moderate ex. can lead to lethal cardiac arrythmia
Gout Manifestation of an inherited inborn error of
purine metabolism Associated with middle age, obesity, Caucasian
race, stress and high dietary intake of purine-rich foods
Medications (penicillin, insulin and diuretics) may also increase uric acid levels
Uric acid is not excreted normally in patients with gout. Instead it changes into crystals and is deposited in the joints (gouty arthritis) or the kidneys (renal disease).
Gout
Peripheral joints of the hands and feet are most often affected. 90% of attacks occur at the MTP of the great toe.
Large tophi occur on the joints and may erupt and discharge masses of urate crystals.
Metabolic Bone Disorders
Osteoporosis Osteomalacia Rickets Paget’s disease
Demographics of Osteoporosis
>10 million people diagnosed in the U.S. Results in about 1.5 million fractures/year in
the U.S. Economic cost >$15 billion/year After osteoporotic hip fracture- 5-24% will die within one year
- 50% of survivors will be incapacitated
- 20% require long-term nursing care
.
Osteoclasts OsteoblastsCoupling
Osteoporosis
Osteoporosis
Result of an uncoupling of the remodeling process
Due to:- enhanced recruitment of osteoclasts
- increased activity of osteoclasts, or
- impaired activity of osteoblasts
OsteoporosisDespite the mechanism or cause, the net result is:
RESORPTION > FORMATION
____________________________________________________________________
OC OB OC OB OC OB OC OB
Normal Osteoclast activity > osteoblast activity
Osteoporosis Risk Factors
Medications:
Corticosteroids
Loop diuretics
Cytotoxics, immunosuppressants
Anticonvulsants
Non-modifiable:
Sex Race
Age Family history
Menarche Menopause
Body Frame Fracture
Modifiable:
Calcium intake Exercise
Smoking Caffeine
Alcohol abuse Sodas
Low body weight (< 127 lbs)
Diseases:
Hyperparathyroidism
Cushing’s disease
Anorexia nervosa
Female athlete syndrome
Hyperthyroidism
Chrischilles EA, et al. Arch Intern Med. 1991;151:2026-2032. Melton LJ, et al. J Bone Miner Res. 1992;7(9):1005-1010.
OsteoporosisOsteoporosis
40% to 54% of women aged 50 years or older
are expected to sustain
an osteoporosis-related fracture
within their lifetime
Fractures are the main
complications of osteoporosis
Fractures are the main
complications of osteoporosis
Sta
nd
ard
De
via
tio
n
Age in Years
5010 20 40 60 70 80 9030
- 2.5 - 2.5
- 1.0 - 1.0
OSTEOPOROSISOSTEOPOROSIS
Peak Bone MassPeak Bone Mass
OSTEOPOROSISOSTEOPOROSIS
- 2.5- 2.5
Sta
nd
ard
De
via
tio
n
Age in Years
5010 20 40 60 70 80 9030
MENOPAU
SE
- 2.5 - 2.5
- 1.0 - 1.0
OSTEOPOROSISOSTEOPOROSIS
Peak Bone MassPeak Bone Mass
OSTEOPOROSISOSTEOPOROSIS
OSTEOPENIAOSTEOPENIA
NORMALNORMAL
Osteoporosis
Clinical signs and symptoms:- Back pain: Episodic, acute low thoracic/high lumbar
pain
- Spinal compression fractures
- Bone fractures (age related)
- Kyphosis
- Dowager’s hump
- Decreased activity tolerance
- Changes are not detectable by X-ray until 30% loss
Osteomalacia
Softening of the bones Due to impaired mineralization of the bone
matrix Results in a decreased rate of bone
formation Caused by Vitamin D deficiency in adults
Osteomalacia
Characterized by decalcified bones, especially the spine, pelvis and LEs
Radiographs reveal bilateral
“pseudofractures” known as
Looser’s transformation zones Most commonly affects the ribs, long bones,
lateral scapula, upper femur and pubic rami
Osteomalacia
Common symptoms include:- Severe bone pain
- Skeletal deformities
- Fractures
- Severe muscle weakness Symptoms sometimes mimic polymyositis
or muscular dystrophy
Rickets
Childhood disease similar to osteomalacia Classic sign is bowing of the long bones “Rachitic rosary” – Widening, fraying and
clubbing of the areas of active bone growth, especially the metaphyseal ends on the long bones and the sternal ends of the ribs
Paget’s disease
Focal inflammatory disorder that produces disordered bone remodeling
Increased bone formation and bone resorption
Bones are enlarged, less compact, more vascular and more susceptible to fracture than normal bone
More common in men than women
Increased bone formation & bone resorption
Abnormal architecture
Larger bones, but weak, easily deformed
Paget’s disease of bonePaget’s disease of bone
Paget’s disease
Many are asymptomatic When present, patients describe bone pain as
aching, deep and boring, worse at night, and diminishing but not disappearing with activity
May have referred muscular pain Other complications include nerve compression
syndromes, secondary osteoarthritis, and vertebral compression and collapse
References Boissonnault JS, Madlon-Kay D.1995. Screening for Endocrine System Disease. In: Boissonnault
editor: Examination in Physical Therapy Practice Screening for Medical Disease. 2nd edition. Philadelphia, PA: Churchill Livingstone, p155-173.
“Bulge Sign”. Retrieved 06/21/08 from the World Wide Web: www.netterimages.com/image/bulge-sign.htm
“Frozen Shoulder and Diabetes”. Retrieved 06/21/08 from the World Wide Web: http://www.diabetesmonitor.com/b240.htm.
Goodman CC, Snyder TE. 2007. Screening for Endocrine and Metabolic Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p467-516.
“Gout”. Retrieved 06/21/08 from the World Wide Web: www.myfootshop.com/detail.asp?Condition=gout.
“Looser zone of osteomalacia in outer aspect of proximal femur”. Retrieved 06/21/08 from the World Wide Web: http://imaging.consult.com/articleSearch?query=femur
Owens B. 2004 Nov 20. Dose-dependent effects of salmon calcitonin on bone turnover inovariectomized rats. http://etd-submit.etsu.edu/etd/theses/available/etd-1120104-223525/.
Rubin E., Farber, J.L. 1999. Pathology. 3rd edition. Philadelphia: Lippincott Williams & Wilkins, p1193. In Porth editor: Pathophysiology Concepts of altered Health States, 6th edition. Philadelphia, PA: Lippincott Williams & Wilkins, p921.
Thomas SJ, et al. 2007. Prevalence of symptoms and signs of shoulder problems in people with diabetes mellitus. J Shld Elbow Surg 16(6):748-51.
www.myfootshop.com/detail.asp?Condition=gout. Accessed on the World Wide Web 6/21/08.
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