Musculoskeletal Manifestations of Thyroid Disease

Thyroid Gland Disorders and Physical Activity: Can They Affect Each Other?

Physical activity (PA) plays a crucial role in promoting emotional well-being, quality of life, and social interaction. Thyroid dysfunction can significantly affect the ability to engage in PA. This review aims to explore the relationship between thyroid disorders and PA. A comprehensive review of the international literature was conducted, including 24 scientific studies that investigated the effects of thyroid dysfunction on exercise in both human and animal models, with and without thyroidectomy. The findings indicate that thyroid disorders are associated with a variety of conditions, including cardiovascular, metabolic, neuromuscular, musculoskeletal, and psychiatric disorders. Additionally, PA has been identified as a beneficial intervention for the management of these conditions. Further studies are needed to determine the most appropriate types and intensities of PA for people before and after thyroidectomy.

The causal relationship between thyroid dysfunction and carpal tunnel syndrome: A Mendelian randomization study

Mendelian randomization was used to investigate the causal relationship between thyroid dysfunction (including hypothyroidism and hyperthyroidism) and carpal tunnel syndrome. Genetic loci independently associated with hypothyroidism and hyperthyroidism were selected as instrumental variables from pooled data from genome-wide association studies. Inverse variance weighting (IVW) was used to analyze the causal effect, supplemented by weighted median and MR-Egger. Heterogeneity test, pleiotropy testing and leave-one-out analysis were used to analyze the sensitivity test to explore the robustness of the results. Both hypothyroidism and hyperthyroidism increase the risk of carpal tunnel syndrome (hypothyroidism: IVW, OR = 1.04, 95% CI = 1.01-1.08, P = .017; hyperthyroidism: IVW, OR = 1.08, 95% CI = 1.05-1.12, P = 9.218E-06, no pleiotropy was found in both tests. Patients with thyroid dysfunction have an increased risk of carpal tunnel syndrome.

Acute arthritis revealing Hashimoto's thyroiditis

Rheumatic manifestations can reveal hypothyroidism, such as arthritis and nonspecific musculoskeletal symptoms. We report herein the case of an acute polyarthritis revealing Hashimoto's thyroiditis (HT). Hormone replacement therapy leads to the resolution of arthritis related to HT, suggesting the role of thyroid hormone in the pathogenesis of arthritis.

Is it really myositis? Mimics and pitfalls

Idiopathic inflammatory myopathies are a heterogeneous set of systemic inflammatory disorders primarily affecting muscle. Signs and symptoms vary greatly between and within subtypes, requiring supportive laboratory and pathologic evidence to confirm the diagnosis. Several studies are typical assessments for patients with suspected inflammatory myopathy, including muscle enzymes, autoimmune markers, imaging, and muscle biopsy. Misdiagnoses of myositis are not only related to the overlap of clinical phenotype with non-inflammatory myopathies, but also due to the limitations of diagnostic tests employed. Since many of the investigative tests are non-specific, they share features with other disorders, including muscular dystrophies, endocrine, toxic, and metabolic myopathies, and other neuromuscular or rheumatologic conditions. Recognizing the limitations of tests and understanding the shared features between inflammatory and non-inflammatory myopathies can help prevent misdiagnosing myositis with one of its several mimics.

Carbimazole induced rhabdomyolysis

SUMMARY

Carbimazole is a commonly used antithyroid drug (ATD), which is associated with several well-established side effects. However, Carbimazole-induced rhabdomyolysis is rarely reported in the literature. We report a 27-year-old male who presented with upper limb myalgia and significantly raised creatine kinase elevation, 1-month post commencement of Carbimazole for Graves' disease. Carbimazole was ceased with subsequent clinical and biochemical improvement. Though the pathophysiology remains unclear, we hope to raise awareness regarding this rare adverse effect with a view to promote early recognition and prompt discontinuation of the offending medication caused by a commonly used medication in endocrinology.

LEARNING POINTS

Musculoskeletal complaints can relate to unidentified and untreated hyperthyroidism. However one must be mindful that the treatment for these disorders can too induce myopathies. ATD-induced myopathy should be considered when there is a temporal relationship between introduction of ATDs and the onset of symptoms. If ATD-induced myopathy is being considered, other causes of myopathy should still be outruled. Prompt discontinuation of potentially offending medications may provide resolution of symptoms and avoid significant consequences.

Incidence of thyroid disease in patients with forefoot deformity

BACKGROUND

Hallux valgus and lesser toe deformities are common foot disorders with substantial functional consequences. While the exact etiologies are multi-factorial, it is unknown if certain endocrine abnormalities, such as thyroid dysfunction, may be associated with these pathologies. The current study sought to investigate the prevalence of thyroid disease in patients with hallux valgus or lesser toe deformities.

METHODS

Every new patient who presented to our institution's foot and ankle clinic during a three-month time period was given a survey to determine the presence of a known thyroid disorder. The diagnosis for each visit was then recorded. Additionally, a national, publicly available database was queried for patients diagnosed with thyroid disease and concomitant hallux valgus or specific forefoot pathology. Odds ratios for the presence of thyroid dysfunction were then calculated for each patient group.

RESULTS

Three-hundred and fifty initial visit patient surveys were collected, and 74 (21.1%) patients had a known diagnosis of thyroid disease. The most common diagnoses were primary hypothyroidism (n = 61, 17.4%), secondary hypothyroidism (n = 6, 1.7%), thyroiditis (n = 4, 1.1%), and hyperthyroidism (n = 3, 0.9%). Thyroid disease was present in 16 of 26 patients (61.5%) with a diagnosis of hallux valgus (OR 7.3, CI[3.16-16.99], p < 0.0001). Lesser toe deformities, including hammertoes, mallet toes, bunionettes and crossover toes, were also significantly associated with thyroid disease (OR 5.45, CI[1.83-16.26], p < 0.002). The national database revealed 905,924 patients with a diagnosis of a specific forefoot deformity, and 321,656 of these patients (35.5%) had a concomitant diagnosis of a thyroid condition (OR 2.11, CI[2.10-2.12], p < 0.0001).

CONCLUSIONS

The current study suggests a significant association between forefoot pathology and thyroid dysfunction, especially hallux valgus and lesser toe deformities. Increased understanding of these correlations may offer an important opportunity in population health management, both in diagnosis and treatment. While further studies with long-term outcomes are necessary, the early diagnosis of thyroid disease may provide an opportunity to predict and potentially alter the course of forefoot pathology.

Assessment of the relationship between knee ultrasound and clinical symptoms in patients with thyroid dysfunction

Objective

To determine whether musculoskeletal ultrasound (MSUS) abnormalities were associated with thyroid dysfunction.

Methods

This study included 109 patients with thyroid diseases, including thyroid dysfunction or autoimmune thyroid disease. Patients were categorized as euthyroid, hypothyroid, or hyperthyroid based on their recent thyroid function tests. To evaluate MSUS, an experienced rheumatologist examined the presence of synovial fluid, synovial hypertrophy, and grade of inflammation in both gray-scale and power Doppler scans of the knee joint. Associations between MSUS abnormalities, thyroid status, visual analog scale (VAS) score for knee pain, and presence of thyroid autoantibodies were investigated.

Results

MSUS abnormalities were more frequently associated with hyperthyroid or hypothyroid states than with a euthyroid state. High knee VAS score was significantly associated with overall MSUS severity score regardless of knee osteoarthritis. However, there was no difference in MSUS abnormalities based on the presence of thyroid autoantibodies.

Conclusions

Both hypothyroid and hyperthyroid states were associated with MSUS abnormalities and knee arthralgia. MSUS examination may be helpful in uncontrolled thyroid dysfunction and knee arthralgia.

THYROID ACROPACHY: A RARE MANIFESTATION OF GRAVES DISEASE IN JOINTS

Objective

The objective of this report was to describe a patient with Graves acropachy, a rare manifestation of Graves disease (GD) that is clinically defined by skin tightness, digital clubbing, small-joint pain, and soft tissue edema progressing over months or years with gradual curving and enlargement of the fingers.

Methods

The patient was evaluated regarding thyroid function (serum free T4 [FT4] and thyroid-stimulating hormone [TSH] quantifications) and autoimmunity biomarkers (thyroid receptor antibody [TRAb]) as well as radiographic investigation of the extremities.

Results

A 52-year-old man presented with a history of thyrotoxicosis and clinical signs of Graves orbitopathy. Laboratory tests showed suppressed TSH (0.01 UI/L; normal, 0.4 to 4.5 UI/L) and elevated serum FT4 (7.77 ng/dL; normal, 0.93 to 1.7 ng/dL), with high TRAb levels (40 UI/L; normal, <1.75 UI/L). A diagnosis of thyrotoxicosis due to GD was made and the patient was treated with methimazole. After the patient complained of swelling in hands and feet, X-ray evaluation was conducted and established the thyroid acropachy.

Conclusion

We present a case of a patient with GD associated with worsening extrathyroid manifestations during orbitopathy, dermopathy, and developed acropachy in hands and feet.

Prevalence of temporomandibular disorders in patients with Hashimoto thyroiditis

OBJECTIVES

Autoimmune thyroid disease (AITD), also known as Hashimoto thyroiditis (HT), is a degenerative inflammatory disease with high prevalence among women and has been associated with fibromyalgia and widespread chronic pain. The goal was to determine the frequency of temporomandibular disorders (TMD) in patients with HT.

METHODS

In all, 119 women (age 19-60 years) were divided into a study (52 women diagnosed with HT) and a control (67 healthy individuals, of which 15 were excluded) group. Serum concentrations of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), anti-thyroglobulin (Tg) and anti-thyroid peroxidase (TPO) antibody levels were measured. The temporomandibular jaw and muscles were examined using the German Society of Functional Diagnostics and Therapy guidelines. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) was used to assess TMD. Standardized questionnaires, incorporating epidemiological criteria, state and treatment of the thyroid disease, Helkimo Index (HI), and Fonseca Anamnestic Index (FAI), were filled out by all patients.

RESULTS

The two groups did not differ in terms of demographic parameters or mandibular jaw mobility. Significantly higher levels of anti-TPO and anti-Tg were attested in all subjects of the HT group. Markedly elevated prevalence of TMD was found in the HT group. Muscle pain and stiffness were found in 45 (86.5%) subjects of the HT group (p < 0.001), of whom 33 (63.4%) also had disc displacement with reposition (p < 0.001). Whereas 50% of the control group showed no TMD symptoms, all subjects in the HT group had symptoms.

CONCLUSIONS

A significantly elevated prevalence of TMD was found in patients with HT. Thus, patients with TMD who do not respond to therapy should be referred for thyroid diagnostic workup.

Utility of rituximab treatment for exophthalmos, myxedema, and osteoarthropathy syndrome resistant to corticosteroids due to Graves' disease: a case report

Background

Exophthalmos, myxedema, and osteoarthropathy syndrome is a very rare condition that is associated with Graves’ disease. The presence of dermopathy and the involvement of joint/bone tissues indicate that it seems to be related with the severity of the autoimmune process. Owing to its low incidence, there is a lack of information regarding its treatment and clinical follow-up. Some cases improved after use of high doses of steroids; however, some patients do not respond to this treatment. Recently, the effectiveness of rituximab for treatment of Graves’ ophthalmopathy resistant to corticosteroids has been demonstrated. However, it has never been used for the treatment of exophthalmos, myxedema, and osteoarthropathy syndrome (particularly for the treatment of osteoarticular manifestations).

Case presentation

We present the case of a 54-year-old Mexican woman previously treated for Graves’ disease who developed post-iodine hypothyroidism and exophthalmos, myxedema, and osteoarthropathy that did not improve after high doses of steroids (intravenous and oral). Her exophthalmos, myxedema, and osteoarthropathy syndrome symptoms improved as early as 6 months after treatment with rituximab.

Conclusion

Exophthalmos, myxedema, and osteoarthropathy syndrome is a non-classical presentation of Graves’ disease, whose clinical manifestations could improve after treatment with rituximab, particularly in those patients with lack of response to high doses of corticosteroids.

Thyroid Disorders in Athletes

When athletic performance begins to deteriorate, it is important to identify possible underlying etiologies to explain such a phenomenon. Causes include inadequate nutrition, improper training habits, infection, and hematologic or endocrine diseases. In athletes, a thorough investigation of potentially reversible underlying medical conditions may be warranted when there are noted disruptions in training, competition, and recovery. Thyroid disorders should be considered in athletes in whom such a condition is suspected. The clinical picture may not be entirely clear, as athletes may have serum laboratory values that do not accurately correlate with the presenting signs and symptoms, as one might expect. That picture is even further muddled in individuals undergoing significant physiologic stress, and in whom anabolic agents or exogenous thyroid hormone are used. Because there are currently no consensus guidelines on the matter, return to play issues must be addressed when implementing treatment strategies and monitoring serial laboratory values on a case-by-case basis.

What is the role of systemic conditions and options for manipulation of bone formation and bone resorption in rotator cuff tendon healing and repair?

Rotator cuff pathology is a significant cause of shoulder pain. Operative repair of rotator cuff is an established standard of care for these patient, however, failure of the procedure is common. Systemic conditions such as diabetes mellitus, hypocholesteremia, thyroid disease, and smoking significantly affect the outcomes of rotator cuff repair and have significant implications for the management of these patients. Diabetes mellitus has been proposed to damage tendons through non-enzymatic glycosylation of collagen with advanced glycation end product formation and impaired microcirculation. Hypocholesteremia may lead to fatty infiltration and subsequent pro-inflammatory degenerative enzymatic degeneration. Thyroid disease may disrupt tendon homeostasis through the alteration of collagen production and the accumulation of glycosaminoglycans. Lastly, smoking inhibits tendon healing through the induction of hypovascularity and hypoperfusion. Understanding of the implications these systemic conditions have on the outcomes is important in the management of rotator cuff disease.

Diagnostic difficulties by the unusual presentations in children and adolescents with Hashimoto thyroiditis

Complex clinical presentation with diverse timing of particular symptoms may cause diagnostic difficulties, especially in children and adolescents. This paper presents diagnostic difficulties and pitfalls in 3 children with acquired primary hypothyroidism due to Hashimoto's thyroiditis (HT) presenting with unusual manifestations. We described 3 children with acquired primary hypothyroidism due to HT. One of our patients had musculoskeletal pain and was diagnosed and treated as having connective tissue disease. Another patient presented with chest pain, dyspnea, and swelling in the abdomen. She had a massive pericardial effusion (PE). Two patients had severe growth failure. A third patient with Down syndrome had a small PE. Her complaint was dyspnea during sleep. All patients improved with thyroxin therapy. Patients with hypothyroidism due to HT who have complicated clinical manifestations were misdiagnosed and mismanaged at childhood and adolescence. Growth failure is an important sign in children and adolescents. In the presence of complicated manifestations in children and adolescents, thyroid dysfunction must be considered in differential diagnosis.

Influence of Thyroid Hormones on Tendon Homeostasis

Tendinopathies have a multifactorial etiology driven by extrinsic and intrinsic factors. Recent studies have elucidated the importance of thyroid hormones in the alteration of tendons homeostasis and in the failure of tendon healing after injury. The effects of thyroid hormones are mediated by receptors (TR)-α and -β that seem to be ubiquitous. In particular, T3 and T4 play an antiapoptotic role on tenocytes, causing an increase in vital tenocytes isolated from tendons in vitro and a reduction of apoptotic ones; they are also able to influence extra cellular matrix proteins secretion in vitro from tenocytes, enhancing collagen production. From a clinical point of view, disorders of thyroid function have been investigated only for rotator cuff calcific tendinopathy and tears. In this complex scenario, further research is needed to clarify the role of thyroid hormones on the onset of tendinopathies.

Anti-thyroid drugs-related myopathy: is carbimazole the real culprit?

INTRODUCTION

Anti-thyroid drugs (ATDs)-related myopathy is rarely reported in literature, but once developed, it can cause significant morbidity to patient.

CASE PRESENTATION

A 28-year old Chinese female was treated with carbimazole (CMZ) for Graves' disease with hyperthyroidism. Two weeks later, she developed myalgia and proximal muscle weakness. Investigations showed evidence of myopathy. CMZ was stopped and rapid improvement of clinical condition and biochemical parameters ensued.

CONCLUSIONS

Rapid decrement of thyroid hormone level is recognized as an important association for anti-thyroid drugs (ATDs)-related myopathy; however, the drug effects on muscle tissue cannot be excluded. Further elucidation of pathophysiology and identification of risk factors are needed. After commencing ATDs, early recognition of this rare condition and close monitoring are the essence of management. Different treatment strategies: dose reduction of ATDs, switching to alternative ATDs, with or without addition of thyroid hormone supplement can be applied depending on clinical situation.

Musculoskeletal manifestations of endocrine disorders

Endocrine disorders can lead to disturbances in numerous systems within the body, including the musculoskeletal system. Radiological evaluation of these conditions can demonstrate typical appearances of the bones and soft tissues. Knowledge of these patterns can allow the radiologist to suggest a diagnosis that may not be clinically apparent. This review will highlight the typical musculoskeletal findings of acromegaly, hypercortisolism, hyperthyroidism, hypothyroidism, hyperparathyroidism, pseudo- and pseudopseudohypoparathyroidism, and diabetes mellitus. The radiological manifestations of each of these endocrine disorders, along with a brief discussion of the pathophysiology and clinical implications, will be discussed.

Fibromyalgia: A Clinical Update

Fibromyalgia is a common chronic syndrome defined by core symptoms of widespread pain, fatigue, and sleep disturbance. Other common symptoms include cognitive difficulty, headache, paresthesia, and morning stiffness. Fibromyalgia is increasingly understood as 1 of several disorders that are referred to as central sensitivity syndromes; these disorders share underlying causes and clinical features. Tender points are often detected in patients with fibromyalgia and were formerly required for diagnosis. Newly proposed criteria, however, rely on patients' reports of widespread pain and other somatic symptoms to establish the diagnosis of fibromyalgia. The management of fibromyalgia requires a multidimensional approach including patient education, cognitive behavioral therapy, exercise, and pharmacologic therapy. The present review provides an update on these various aspects of treating a patient with fibromyalgia.

Correlation of clinical changes with regard to thyroxine replacement therapy in hypothyroid patients: focusing on the change of renal function

Thyroid dysfunction has an important role in renal insufficiency. The aim of the study was to correlate the change of renal function with other clinical factors after thyroxine therapy in hypothyroid patients. A prospective study was designed and 30 hypothyroid patients were included. All study subjects received 0.15-0.2 mg/day thyroxine for 12 weeks. Diastolic blood pressure and serum levels of creatine phosphokinase (CPK) and myoglobulin decreased significantly after thyroxine therapy. Serum creatinine decreased (0.87 ± 0.22 vs. 0.70 ± 0.17 mg/dl, p < 0.001) and estimated glomerular filtration rate (eGFR) increased significantly (82.06 ± 31.08 vs. 100.31 ± 31.79 ml/min/1.73 m(2); p < 0.001) after thyroxine replacement. Left ventricular ejection fraction (LVEF) was significantly increased after thyroxine replacement (64.47 ± 11.94 vs. 72.40 ± 13.89%, p = 0.026). No significant vascular functional changes of peripheral (pulse wave velocity) and renal interlobar arteries (pulsatility index and resistance index) were noted. The change of eGFR significantly correlated with the changes of serum-free T(4) (fT(4)), CPK, myoglobulin and LVEF. The correlation between the change of eGFR and thyroid-stimulating hormone (TSH) level was not significant. In conclusion, the GFR of hypothyroid patients increased significantly after thyroxine replacement. The change of GFR was significantly correlated with the changes of fT(4), CPK, myoglobulin and LVEF, but not with TSH.