Insulin Resistance Screening in Perimenopausal Musculoskeletal Care: A Functional Medicine-Informed Framework

Tara Moore, PT, DPT, MEd, NTP, IFMCP

Tara Moore, PT, DPT, MEd, NTP, IFMCP, Founder and Physical Therapist, Obsidian Insight, Richfield, Ohio, USA.

Corresponding author: Tara Moore, PT, DPT, MEd, NTP, IFMCP  

E-mail: tara@obsidian.health

Keywords: Perimenopause, Insulin resistance, Musculoskeletal rehabilitation, Metabolic risk assessment, Resistance training, Women’s health

Introduction

Women in perimenopause commonly present to clinicians who focus on musculoskeletal complaints with new or persistent joint pain, myalgia, and tendon-related symptoms. The emerging construct of a “musculoskeletal syndrome of menopause” recognizes these presentations as manifestations of a broader physiologic transition rather than isolated tissue pathology.¹

In many settings, management remains centered on localized tissue rehabilitation, with less attention to systemic contributors that may influence recovery. As a result, some women continue to experience functional limitations despite adherence to recommended strategies.

One systemic contributor warranting greater attention during this life stage is metabolic dysfunction, particularly insulin resistance. During the menopausal transition, declining estradiol alters insulin receptor signaling and glucose homeostasis, contributing to increased visceral adiposity and reduced insulin sensitivity beyond expected age-related changes.^2,3 Since skeletal muscle is the primary site of insulin-mediated glucose disposal, these shifts are directly relevant to musculoskeletal function and recovery.⁴ Furthermore, longitudinal data demonstrate worsening cardiometabolic risk across this transition.⁵

Type 2 Diabetes is associated with increased prevalence of tendinopathy and related conditions.6 Metabolic and inflammatory changes accompanying insulin resistance may intersect with menopausal connective tissue changes, potentially amplifying symptom persistence or limiting rehabilitation response. Despite these interrelationships, structured metabolic risk awareness remains uncommon in routine outpatient musculoskeletal evaluation.

This clinical innovation proposes a functional medicine–informed framework (Figure 1) integrating early metabolic risk awareness into musculoskeletal care for perimenopausal women to enhance personalization and interdisciplinary collaboration.

Figure 1. Systems Pathway Linking Perimenopause, Insulin Resistance, and Musculoskeletal Care

Systems Framework

This framework applies a systems-based lens by considering medical history and lifestyle factors that contribute to insulin resistance and musculoskeletal dysfunction in perimenopausal women. Antecedents may include endocrine history (e.g., polycystic ovarian syndrome), long-standing sedentary behavior, and nutritional patterns that influence metabolic regulation across the lifespan. Common triggers during perimenopause include hormonal shifts, central weight redistribution, psychosocial stress, and sleep disruption. These factors may impair insulin sensitivity, increase inflammatory signaling, and reduce tissue recovery capacity. Mediators sustaining dysfunction may involve chronic low-grade inflammation, impaired glucose utilization within skeletal muscle, altered collagen turnover, and physical inactivity.⁷

Sleep disruption and chronic psychosocial stress are common during perimenopause and may impair insulin sensitivity and amplify pain perception.^8,9 Incorporating sleep hygiene strategies, circadian rhythm stabilization, stress regulation techniques, and appropriate workload management may enhance both metabolic regulation and musculoskeletal recovery. Although clinicians may not directly manage all behavioral interventions, acknowledging these contributors during evaluation can meaningfully shape the plan of care to include within-scope strategies such as education, exercise dosing and pacing, and appropriate referral. This approach extends rehabilitation beyond localized tissue treatment toward more integrated, whole-person care that supports symptom improvement and continuity.

Patterns such as excessive fatigue, fluctuating symptoms, reduced tolerance to loading, or delayed recovery should prompt consideration of metabolic and lifestyle contributors rather than attributing symptoms solely to compliance, aging, or localized biomechanical factors.

This framework incorporates structured metabolic risk awareness into routine musculoskeletal evaluation for perimenopausal women. Screening does not establish a diagnosis but raises clinical suspicion and informs care planning. Assessment may include validated diabetes risk questionnaires consistent with current standards of care, symptom patterns suggestive of glycemic variability, anthropometric indicators such as waist-to-hip ratio, dermatologic markers including acanthosis nigricans, and endocrine antecedents such as polycystic ovarian syndrome, which remains strongly associated with insulin resistance across the lifespan.^10-13 Findings are interpreted within a systems context, considering antecedents, triggers, and mediators that may influence both metabolic and musculoskeletal function. When metabolic risk indicators are identified, referral to primary care clinicians, endocrinologists, menopause specialists, registered dietitians, sleep medicine specialists, or other medical providers may be appropriate. Rehabilitation care continues concurrently for functional progression and metabolic health.

Resistance Training As A Metabolic Intervention

Resistance training has demonstrated improvements in glycemic control and preservation of lean body mass in adults with metabolic dysfunction.^14-16 Meta-analytic evidence indicates that structured resistance training significantly reduces HbA_1c in individuals with type 2 diabetes.¹⁴ Preservation of lean mass and metabolic health is relevant to musculoskeletal resilience during midlife. Since insulin sensitivity improves with progressive resistance loading, therapeutic exercise may serve as both a musculoskeletal and metabolic intervention, supporting glycemic regulation while enhancing tissue capacity and load tolerance. Physical therapists are uniquely positioned to prescribe and modify therapeutic exercise in the presence of pain, tendon pathology, or functional limitation. For perimenopausal women presenting with musculoskeletal features, progressive resistance loading, appropriately modified for symptom severity and tissue tolerance, may support both metabolic and functional outcomes. Rehabilitation programs may extend beyond isolated joint interventions to include full-body resistance strategies that improve metabolic health, acknowledging symptom constraints. Exercise dosage, intensity progression, and recovery intervals are individualized based on symptom patterns and functional response. Education contextualizes musculoskeletal symptoms within broader physiologic transitions, strengthening therapeutic partnership and supporting shared decision-making.

Conclusion

The musculoskeletal syndrome of menopause provides an emerging framework for understanding midlife symptom patterns. Insulin resistance represents a modifiable and underrecognized contributor that may intersect with these musculoskeletal changes through inflammatory, connective tissue, and recovery-capacity mechanisms. Incorporating structured metabolic risk awareness into rehabilitation evaluation may enhance personalized exercise prescription, interdisciplinary collaboration, and support preventive cardiometabolic health during the critical life stage.

Improving insulin sensitivity through resistance training and lifestyle modifications may reduce inflammatory burden and enhance the metabolic environment that supports skeletal muscle and connective tissue recovery. Although direct interventional trials linking insulin-sensitizing strategies to musculoskeletal symptom resolution in perimenopausal women remain limited, established associations between metabolic dysfunction and tendon pathology support consideration of metabolic health as a modifiable contributor to rehabilitation response.

Clinicians focusing on musculoskeletal complaints are uniquely positioned to identify early metabolic dysfunction in perimenopausal women presenting with persistent or disproportionate symptoms. Integrating metabolic risk awareness into routine evaluation enables timely referral while continuing to target rehabilitation that supports functional activities and metabolic health. Addressing systemic and mechanical contributors concurrently may reduce diagnostic delay and create a more coherent recovery trajectory. Earlier recognition of metabolic risk in musculoskeletal care may support preventive cardiometabolic health efforts during the menopausal transition, contribute to improved population-level outcomes, positioning rehabilitation professionals as collaborative partners in longitudinal women’s health.

Funding

No funding was received for this project.

References

1. Wright VJ, Schwartzman JD, Itinoche R, Wittstein J. The musculoskeletal syndrome of menopause. Climacteric. 2024;27(5):466-472. doi:10.1080/13697137.2024.2380363
2. Carr MC. The emergence of the metabolic syndrome with menopause. J Clin Endocrinol Metab. 2003;88(6):2404-2411. doi:10.1210/jc.2003-030242
3. Mauvais-Jarvis F. Estrogen and androgen receptors in glucose homeostasis and insulin sensitivity. Nat Rev Endocrinol. 2015;11(10):587-602. doi:10.1038/nrendo.2015.120
4. DeFronzo RA, Tripathy D. Skeletal muscle insulin resistance is the primary defect in type 2 diabetes. Diabetes Care. 2009;32(Suppl 2)(suppl 2):S157-S163. doi:10.2337/dc09-S302
5. Wildman RP, Sowers MR. The timing of the menopause transition and metabolic syndrome risk. Obesity (Silver Spring). 2008;16(12):2737-2742. doi:10.1038/oby.2008.435
6. Ranger TA, Wong AM, Cook JL, Gaida JE. Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. Br J Sports Med. 2016;50(16):982-989. doi:10.1136/bjsports-2015-094735
7. Abate M, Schiavone C, Salini V, Andia I. Occurrence of tendon pathologies in metabolic disorders. Rheumatology (Oxford). 2013;52(4):599-608. doi:10.1093/rheumatology/kes395
8. Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet. 1999;354(9188):1435-1439. doi:10.1016/S0140-6736(99)01376-8
9. Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552. doi:10.1016/j.jpain.2013.08.007
10. American Diabetes Association. Classification and diagnosis of diabetes: standards of Care 2024. Diabetes Care. 2024;47(suppl 1):S20-S42. doi:10.2337/dc24-S002
11. Benites-Zapata VA, Toro-Huamanchumo CJ, Urranaga-Pastro D, et al. Waist-to-hip ratio and insulin resistance markers. Diabetes Metab Syndr. 2019;13(1):636-642. doi:10.1016/j.dsx.2018.11.043
12. Videira-Silva A, Albuquerque C, Fonseca H. Acanthosis nigricans as a clinical marker of insulin resistance among overweight adolescents. Ann Pediatr Endocrinol Metab. 2019;24(2):99-103. doi:10.6065/apem.2019.24.2.99
13. Amisi CA. Markers of insulin resistance in PCOS. World J Diabetes. 2022;13(3):129-149. doi:10.4239/wjd.v13.i3.129
14. Strasser B, Pesta D. Resistance training for diabetes prevention and therapy: experimental findings and molecular mechanisms. BioMed Res Int. 2013;2013:805217. doi:10.1155/2013/805217
15. Umpierre D, Ribeiro PAB, Kramer CK, et al. Structured exercise training and HbA1c. JAMA. 2011;305(17):1790-1799. doi:10.1001/jama.2011.576
16. Peterson MD, Sen A, Gordon PM. Resistance exercise and lean mass. Med Sci Sports Exerc. 2011;43(2):249-258. doi:10.1249/MSS.0b013e3181eb6265