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.