Artwork: medical caduceus.
NOTE: If you have any questions for "Ask the Doctor,"
please send them to the VOICE editorial office. The only questions Dr. Wilson
will be able to answer are the ones used in this column.
Wesley W. Wilson, MD has retired as an Internal Medicine practitioner at the
Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type
1 diabetes in 1956, during his second year of medical school. He remains interested
and involved in diabetes education for patients and professionals.
Q: I am a long term type 1 diabetic with a number of complications. I am having
some odd stiffness in my hands, and am told it is "trigger finger."
What is this, and what can I do about it?
A: I am sorry to hear about your problems with complications
from diabetes. More knowledge is needed, to help persons with diabetes avoid
complications or reverse them if they are present. Careful control of blood
sugars reduces the likelihood of diabetic complications; but such "tight
control" is difficult, and sometimes dangerous; for the tighter the control,
the greater the risk of hypoglycemia (low blood sugars).
Let's talk about those "lows." They're not only frightening and uncomfortable;
a "low" impairs one's judgement, and can lead to accidents and serious
injuries. Most physicians who care for persons who take insulin for their diabetes
can recite at least one serious auto accident in a person who became hypoglycemic
while driving an automobile. It is vitally important to check blood sugars before
driving a car. We diabetics tend to forget to do that; but it is important,
and diabetics do need to safely operate motor vehicles. I remain concerned that
regulatory agencies may wish to remove or restrict driving permits for insulin-using
diabetics.
But, although tight control is difficult, it is possible. After all, 5% of the
tight control participants in the DCCT (the Diabetes Control and Complications
Trial) were able to maintain normal hemoglobin A1cs during the six years of
that study
But back to your "trigger finger" problem. Tendons attach muscles
to movable body parts. For example, a muscle in the arm contracts, pulling on
a tendon attached to the finger, and the finger bends. The tendons move inside
slippery tendon sheaths. If either the tendon or its sheath becomes sticky,
like a rusty cable or a rough pulley, muscle pull on the affected tendon may
result in jerky movement of the finger; or the finger may remain fixed until
the force becomes very high - then it suddenly snaps or bends very quickly,
as if pulling the trigger on a gun. The underlying problem seems to be increased
"stickiness" in the tendon or tendon sheath.
Some people develop "trigger finger" from overuse of certain muscles
or tendons, with inflammatory changes in the tendon or tendon sheath; but persons
with diabetes have an additional problem. Glucose, if attached to the tendon
or tendon sheath, causes stickiness, and this sticky glucose attachment to the
tendons is called glycosylation. The same process of glucose attachment, this
time to the hemoglobin protein in red blood cells, is what is measured in the
A1c or glycosylated hemoglobin test that helps estimate average blood sugar
level. The higher the average blood sugar level, the greater the degree of glycosylation
of proteins, both in the red blood cells, and in places like tendons and tendon
sheaths.
Persons with diabetes may and often do experience sticky tendons in a variety
of spots: "Trigger fingers," "frozen shoulders," or the
medical term "limited joint mobility of diabetes are terms used to describe
manifestations of this problem. These problems may occur even in very carefully
controlled diabetes; but keeping your sugars as near normal as possible is very
important. It's nice to see the glycosylated hemoglobin test is readily available
to see how effective attempts to control blood sugar have been.
You'd like a solution for your problem, and the good news is that often with
blood sugar control, supervised stretching, and careful exercise, the problem
will improve. Be careful not to overuse the affected tendons - attempt to increase
joint mobility only under supervision. Some physical therapists have a good
success rate - and can be found by contacting your diabetes educator or physician.
Anti-inflammatory drugs may help, but these drugs involve particular risks for
persons with diabetes, since they may impair kidney function, especially if
there is already any kidney problem. I'd be very careful about the use of these
agents, either by prescription or over the counter.
Surgery can be helpful, but I feel it is a last resort, since many times the
problem will improve with reduction of overuse, and with careful stretching
and mobility exercise. I would again emphasize the importance of "supervised"
use of the muscles and tendons.
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