Sonographic Findings of Common Musculoskeletal Diseases in Patients with Diabetes Mellitus

Abstract

Diabetes mellitus (DM) can accompany many musculoskeletal (MSK) diseases. It is difficult to distinguish the DM-related MSK diseases based on clinical symptoms alone. Sonography is frequently used as a first imaging study for these MSK symptoms and is helpful to differentiate the various DM-related MSK diseases. This pictorial essay focuses on sonographic findings of various MSK diseases that can occur in diabetic patients.

Keywords: Diabetes mellitus; Musculoskeletal; Sonography.

Fig. 1. Cellulitis with abscess formation of right foot in 49-year-old patient with painful swelling and fever.

A. Longitudinal sonography scan shows diffuse thickening of subcutaneous tissues with large subcutaneous fluid collection (arrows) filled with echogenic material (asterisk). B. Transverse color Doppler sonography scan shows increased vascularity surrounding multiloculated, hypoechoic fluid collection. Streptococcus viridans was cultured from fluid obtained with sonography-guided aspiration. C. Sagittal enhanced T1-weighted fat-suppressed image shows subcutaneous fluid collection with rim-like enhancement. Drain tube is inserted at fluid collection (arrow). Surrounding edema without involvement of deep soft tissue or bony structure is noted.

Fig. 2. Infectious pyomyositis with intramuscular abscess due to Staphylococcus aureus in 36-year-old patient with right thigh pain and fever.

A. Transverse sonography scan of medial thigh shows fluid collection (arrows) with echogenic septa (arrowheads) within vastus medialis muscle. Diffuse edema of adjacent muscles and subcutaneous layer are also noted. B. Axial enhanced T1-weighted fat-suppressed image shows few fluid collections with rim-like enhancement within vastus medialis (arrow), vastus lateralis, and rectus femoris.

Fig. 3. Infectious pyomyositis, tenosynovitis, and cellulitis with abscess due to tuberculosis in 61-year-old patient with right forearm pain and fever.

A. Transverse color Doppler sonography scan at distal radioulnar joint level shows distended flexor tendon sheath (arrows) filled with echogenic debris (asterisk) and hypervascularity. Tendons are mildly thickened. B. Longitudinal sonography scan reveals subcutaneous extension of echogenic debris (asterisk), suggesting ruptured tendon sheath. T = tendon

Fig. 4. Septic arthritis of right hip in 57-year-old patient with hip pain and fever.

A. Longitudinal sonography scan of anterior aspect of right hip joint shows joint distension (arrows), bone destruction (arrowhead), and fluid with echogenic debris (asterisk) with adjacent soft tissue edema. B. Axial enhanced T1-weighted fat-suppressed image shows septic arthritis of right hip and osteomyelitis (asterisk) with pathologic fracture of femur (arrow). Joint fluid and irregular synovial enhancement (arrowheads) are seen.

Fig. 5. Medial arteriosclerosis showing stiff Doppler flow pattern in lower extremity in 60-year-old patient.

A. Longitudinal sonography scan of superficial femoral artery shows continuous echogenic lines (arrows) in vessel wall without luminal narrowing. Doppler flow pattern shows decreased 2nd reversal flow in early diastole and loss of 3rd wave. These findings are suggestive of decreased resistance of distal arteries and arterial stiffness. B. Plain radiography of left knee shows continuous circumferential fine calcification along superficial femoral artery and popliteal tributaries (arrows).

Fig. 6. Neuropathic osteoarthropathy with combined infection (Pseudomonas aeruginosa) of left knee in 61-year-old patient with knee swelling.

A. Transverse sonography scan of suprapatellar bursa shows large amount of joint effusion filled with echogenic material (asterisk) and diffuse thickening of subcutaneous tissues. B. Longitudinal sonography scan of medial aspect of left knee shows cortical destruction of tibia (arrows) and joint effusion with echogenic materials. C. Plain radiography of left knee shows severe bone destruction with discrete margin, fragmentations, joint subluxation, and soft tissue edema. Serial radiographs (not shown) demonstrate rapid progression of bone destruction.

Fig. 7. Carpal tunnel syndrome of left wrist in 58-year-old patient with complaint of tingling sensation of both hands.

A. Transverse sonography of left wrist scan shows palmar bowing of flexor retinaculum at proximal carpal tunnel level delimited by scaphoid (S) and pisiform (P). Diffuse thickening of flexor retinaculum is noted (arrow). B. Transverse sonography scan shows median nerve flattening (asterisk) at distal carpal tunnel level delimited by hamate (H) and trapezium (T). C. Longitudinal sonography scan shows median nerve flattening (asterisk) at distal (dist) carpal tunnel level and median nerve swelling (arrow) at distal radius level (prox). Surgical release of carpal tunnel was performed because of non-responsiveness to conservative management.

Fig. 8. Adhesive capsulitis of right shoulder in 49-year-old patient with bilateral shoulder pain.

A. Transverse color Doppler sonography scan shows thickening of cuff interval structures with increased vascularity (asterisk). Dynamic sonography scan of right shoulder shows marked limitation of sliding movement of supraspinatus tendon beneath acromion during lateral passive elevation of arm (not visualized in this figure). B. Transverse sonography scan shows distension of biceps long head tendon sheath (asterisk) with joint fluid collection. C = coracoid process

Fig. 9. Dupuytren's contracture of right hand in 48-year-old patient complaint of contracture of right 4th finger and palpable nodules on palm.

A. Transverse sonography scans shows hypoechoic nodular lesions (arrows) in subcutaneous fat layer of right palm at 3rd and 4th metacarpal head level, suggesting nodular thickening of palmar fascia. B. On longitudinal sonography scan, subcutaneous cord (arrow) at distal crease level is contiguous with thickened tendon sheath of 4th flexor digitorum tendon. 3rd = 3rd metacarpal head, 4th = 4th metacarpal head

Fig. 10. Trigger finger affecting right 2nd–4th fingers in 38-year-old patient with difficulty in extension of right 2nd–4th fingers.

A. Transverse sonography scan shows hypoechoic nodular thickening of first annular pulleys (arrows) at metacarpophalangeal joint level. B. Longitudinal sonography scan shows blurred margin of 2nd flexor digitorum tendon (arrow). 2nd = 2nd flexor digitorum tendon, 3rd = 3rd flexor digitorum tendon, 4th = 4th flexor digitorum tendon, MC = 2nd metacarpal bone, P = 2nd proximal phalanx

Fig. 11. Diabetic muscle infarction affecting right thigh in 55-year-old patient with leg pain.

A, B. Transverse (A) and longitudinal (B) sonography scans show heterogeneous echogenicity of right vastus lateralis muscle. On longitudinal scan (B), hypoechoic portion with preservation of echogenic fibrillar pattern of muscle fibers (arrow) is noted. Significant fluid collection is absent. C. Axial T2-weighted MR image shows diffuse edema of right vastus lateralis muscle. Note focal T2 low signal intensity lesion (arrow). D. On axial enhanced T1-weighted fat-suppressed MR image, focal T2 low signal lesion corresponds to lesion with decreased enhancement and surrounding enhancement (arrow).