Diabetes mellitus (DM) is a chronic and progressive metabolic disorder characterized by persistent hyperglycemia, which leads to morbidity and mortality due to secondary microvascular and macrovascular complications (1–3). Nowadays, it is one of the most important public health challenges (4, 5) and the fifth leading cause of death globally (6). Approximately 463 million people were affected by DM worldwide (7). It has been estimated that the number will increase to 700 million by the year 2045 (7, 8). Ethiopia is one of the first four countries in sub-Saharan Africa (SSA) to have a higher number of diabetes patients (5.2%) (9).

Although the pathophysiological mechanisms remain unclear, DM can lead to various musculoskeletal complications (2, 10) involving joints, soft tissues, muscles, nerves, and tendons (11). Musculoskeletal disorders are generally not diabetes mellitus specific and can also be seen in the general population. However, its incidence has increased significantly in patients with diabetes mellitus (10). It causes chronic irreversible damage and destructive changes in musculoskeletal and connective tissues associated with severity, duration of diabetes mellitus, and failure in controlling the blood glucose level (11). Evidence suggests that hyperglycemia may accelerate non-enzymatic glycosylation and abnormal collagen deposition in per-articular connective tissues that further alter the structural matrix and mechanical properties of the musculoskeletal system (12). In turn, connective tissue disorders, neuropathy, or micro- and macrovascular complications could have a synergic effect on the development of musculoskeletal complications associated with diabetes mellitus (13). Adhesive capsulitis of shoulder (AC), carpal tunnel syndrome (CTS), Dupuytren’s contracture (DC), trigger finger (TF), De Quervain’s contracture (DQC), and limited joint mobility (LJM) are those more commonly occurring in patients with diabetes mellitus (14–17).

Musculoskeletal disorders can cause pain (18, 19) as well as impairments in the hand and shoulder (20) resulting in loss of body function (11) and activity limitation (21), which is supported by the study conducted in Pakistan that revealed that advanced age, long duration of DM, and female gender were risk factors for shoulder pain and disability (22). It has a significant economic impact on the community due to direct medical and other related costs and disability which results in poor quality of life and health status of individuals with diabetes mellitus (19, 23). Furthermore, it interferes with diabetic care follow-up, work ability, and productivity of the workers (24).

Although the existing literature shows high burden of DM and associated MSKD globally, there is scarcity of evidence in our local arena and little attention is given by the government and other stakeholders. Thus, affected patients may have a decrease in afunctional ability, an increased sedentary lifestyle, and a poor quality of life (12). Therefore, it is important to identify musculoskeletal complications related to diabetes at an early stage to ensure quality of life and prevent long-term disability (25).

Despite the fact that evidence supports the inclusion of physical examination in the evaluation of diabetes mellitus patients, it has yet to be implemented in the national guidelines. Therefore, the study aimed at determining the prevalence and factors associated with MSKD in patients with diabetes attending at the Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, northwest Ethiopia. Besides, conducting the research may offer basic evidence for any interventions aimed at preventing and treating MSKD early and improving their quality of life, and designing effective strategies toward tackling preventable DM-related mortality and morbidity.

The purpose of this study was to find out the prevalence and associated factors of MSKD in patients with diabetes in the Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, northwest Ethiopia. In our study, the prevalence of MSKDs among DM patients was 24% which is higher than in those studies conducted in Ethiopia which is 16.6% (42), Netherlands 16.3% (43), India 19.8% (36), and Saudi Arabia 17.9% (44). Late diagnosis of DM, lack of awareness and screening practices, poor glycemic control, and/or inadequate clinical management of musculoskeletal complications could be attributed to the high burden of MSKD (45). In Ethiopia, a high proportion of diabetic patients had poor glycemic control (46, 47) and poor diabetic self-care practice (48).

However, this result is lower as compared to previous studies done in France at 28.6% (14), Morocco 34.4% (29), India 42.58% (27), Turkey 45.9% (49), Pakistan 46.7% (50), Jordan 69.5% (28), Canada 66% (51), Sweden 65% (52), and Iran 83.5% (53). This difference might be explained by various procedures used to measure the prevalence and the type of DM (either type I only or type II or both). This might be also justified as difference in socioeconomic status and life style. Besides, some studies measured only the shoulder or hand separately to assess MSKD whereas others looked at the whole body including lower-extremity disorders. Individual differences in the provision of healthcare as well as adherence to management to ensure good diabetic control and keep musculoskeletal function supple by modifying life style, engaging in regular physical activity, and strictly adhering to prescribed diet management could also be reasons for non-compliance.

Adhesive capsulitis of the shoulder (10.2%) was the most commonly reported MSKD in our study followed by limited joint mobility 8.2%, carpal tunnel syndrome 5.8%, rotator cuff tendinitis 4.8%, trigger finger 4.1%, De Quervain’s tenosynovitis 3.1%, and Dupuytren’s contracture 2.9%, which is consistent with a previous study done in Pakistan (54) and Iran (38) in which the proportion of adhesive capsulitis of shoulder was 10.9% and 8.79%, respectively. However, the magnitude was higher than that in a study conducted in Saudi Arabia (44).

In our study, the results of multivariate analysis revealed that being female, older age, occupation (farmer, merchant, and being retired) and long duration of DM were factors significantly associated with the presence of one or more MSKD.

Increasing age is a significant risk factor in developing musculoskeletal disorders. Our study found that older adults over the age of 50 were 4.64 times more likely to develop one or more MSKDs than younger participants under the age of 50. This finding is consistent with the studies conducted in Iran (53), Jordan (28), Turkey (49), and India (27). The possible explanation could be that skeletal muscle mass and strength decline with age due to a reduction in the number of muscle fibers and cellular and molecular changes that reduce the force-generated process (19, 55, 56). Loss of bone, articular cartilage degradation, degeneration, and narrowing of the interverbal discs are the primary features of aging. They go through significant biomechanical alternations that directly compromise their biomechanical function, which contributes to the development of MSKD, which also contributes to pain and disability (19, 57).

In our study, MSKD was observed more frequently in female (29.2%) participants as compared with male participants. Hence, female diabetic participants were two times more likely to develop musculoskeletal manifestations as compared to male participants. This was in line with the findings reported from studies done in Ethiopia (42) and Jordan. Consistent with this finding, the review literature revealed that females had a significantly higher incidence of various types of musculoskeletal complications than males (10). Females may have poor glycemic control, less engagement in physical activity, and less adherence to therapy than males, which may contribute to the discrepancy in the findings.

Regardless of the evidence associating occupation with the presence of MSKD in diabetes patients, farmers, merchants, and retirees were associated with the presence of MSKD. Farmers were less likely than housewives to have MSKD. One possible explanation is that farmers were more physically active than housewives, which reduced the likelihood of developing musculoskeletal complications. Merchants, on the other hand, are more likely to have MSKD than housewives. This could also be that the job may contribute for the sedentary lifestyle of merchants. Participants who had retired from their occupation, on the other hand, were three times more likely to have one or more MSKD than housewives. One plausible explanation is that the likelihood of having one or more MSKD increases proportionally with age according to the finding from our study.

The presence of one or more MSKD was significantly associated with the duration of DM in our study. Study participants living with DM for more than 10 years had 4.3 times higher odds of developing MSDs than those participants with a diabetes duration of less than 5 years. The findings in our study were supported by studies done in Jordan (28),Turkey (49), and India (27). The most likely explanation is that musculoskeletal changes may progress in a proportional manner as the duration of diabetes increases.

Our study has certain potential shortcomings that point to the coming research. First, it was conducted in a single health institution with a homogenous study population, which may limit our ability to conclude. Second, our study is cross-sectional, which limits our capacity to establish a casual relation between explanatory and response variables. Finally, due to the incapability of imaging and laboratory study to diagnose prevalent MSKD such as osteoarthritis, we do not include them.

In this study, approximately one-quarter of the study participants had MSKD. Being older, female sex, retired, occupation, and having diabetes for a longer period of time were significantly associated with the occurrence of one or more musculoskeletal disorders in patients with diabetes.

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by the School of Ethical Review Committee. The patients/participants provided their written informed consent to participate in this study.

All authors contributed to the data analysis, drafting, or revising of the article, gave final approval of the manuscript to be published, and agree to be accountable for all aspects of the work.

The research project was funded by University of Gondar.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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