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Advertisement

Foot and ankle

exercises in
patients with
diabetes
2011, FEATURE ARTICLE, JANUARY | 0 COMMENTS
 Guidelines recommend
cardiovascular and strengthening exercises in patients with
diabetes, but flexibility exercises focused on the foot and ankle
can impart added benefits. Improving range of motion can
positively affect gait, pressure distribution, and risk of foot
ulceration.
By Pamela D. Ritzline, PT, EdD, and Audrey Zucker-Levin, PT, PhD.
Diabetes mellitus (DM) is a chronic, systemic disorder that disturbs the
body’s insulin mechanisms, altering blood glucose levels, which can lead
to severe health problems and disability. DM is epidemic worldwide with
1

a significant number of people in the United States having this condition.

The American Diabetes Association (ADA) reports 23.6 million children
and adults in the U.S. have diabetes, with 17.9 million diagnosed, 5.7
million undiagnosed, 57 million in a pre-diabetes state, and 1.6 million
new cases diagnosed annually in persons 20 years of age and older (most
recent data gathered in 2007). DM is the seventh leading cause of death
in the U.S., contributing to 233,619 deaths in 2005 (last year data
available). The cost of diabetes care was $174 billion in 2007. The
2

number of individuals affected by this disease continues to rise;

therefore, holistic care is imperative to control the functional limitations
affecting patients with DM.
As the incidence of DM rises, healthcare professionals must recognize
the risk factors contributing to the development of the disorder. The list
is quite lengthy; however, the common risk factors include obesity,
physical inactivity, elevated blood glucose, hypertension (> 140/90),
smoking, family history, and abnormal lipid metabolism. The incidence of
DM increases with age with men having a slightly greater risk than
women, and African Americans having the greatest risk of developing
DM. The more risk factors a person has, the greater the risk of
2

developing type 2 diabetes and associated medical problems. Associated

medical problems include cardiovascular disease, peripheral neuropathy,
retinopathy, renal failure, dental disease, erectile dysfunction,
ketoacidosis, hyperlipidemia, cognitive impairment, an increased
susceptibility to other illnesses such as pneumonia or influenza,
decreased range of motion of the feet and ankles, balance impairment,
and non healing ulcers that may lead to amputation. 2

Exercise and diabetes

The benefits of exercise for

the diabetic population are widely described in the literature. Although a
detailed discussion of the evidence supporting the need for exercise in
persons with type 2 diabetes is beyond the scope of this article, a
preponderance of such evidence exists. 2-18
A Pubmed/Medline search using
the words “diabetes, exercise, training” yielded 2481 citations. Culling
through the citations revealed studies with outcomes that supported
exercise for improving VO2max anaerobic threshold, time to anaerobic
threshold, improving endurance, improving strength, improving
3 3,4 5-8

metabolic control, 9-12

improving emotional well being, and improving
8,9

mental health and vitality while decreasing metabolic syndrome risk

8

factors decreasing insulin requirement,

13 9,11
and decreasing
falls. 14,15
Exercise also has been shown to increase the cells’ sensitivity to
insulin, improve blood glucose control (decreasing the amount of
medications necessary) decrease hypertension, improve lipid metabolism
2

leading to a healthier heart, assist with weight control, reduce

cardiometabolic risks, improves sleep patterns and energy levels, reduce
stress, increase flexibility, and build stronger bones and muscles. 2,16-18
No
negative effects from exercise were discovered in the citations reviewed.
The extensive literature review revealed that exercise interventions
varied in longevity (from one week to a lifetime), in duration (from two to
seven days per week), and in intensity. Some interventions focused on
cardiovascular fitness, others on muscle strengthening, balance, and/or
flexibility. Some programs incorporated multiple interventions. So,
which exercises are most beneficial and how do we assure compliance
long term?
Five basic categories of exercise are recognized: cardiovascular,
strength, flexibility, balance, and cognitive. The U.S. federal government
has published Physical Activity Guidelines for all Americans, including
those with chronic disease such as diabetes. The guidelines clearly state
1

that adults should participate in a total of 150 minutes of moderate-

intensity or 75 minutes of vigorous-intensity aerobic physical activity per
week. Exercise should be spread over the entire week with sessions
divided into 10 minute intervals. The simplest exercise would be to
encourage individuals to walk at a vigorous pace while wearing
appropriate footwear. Other options involve use of equipment such as a
bicycle, elliptical, stepper, or treadmill to accomplish the cardiovascular
requirement. 1

The guidelines also recommend that adults perform at least twice weekly
strengthening exercises of all major muscle groups. People can be
instructed in exercises that use bodyweight as resistance or machines for
resistance. Major muscle groups include the quadriceps, hamstrings,
calves, abdominals, biceps, triceps, and forearms. Guidelines vary on
intensity and frequency, with benefits reported from performing one set
of 15 moderate intensity repetitions to three sets of 15 repetitions of low
intensity repetitions. The frequency and intensity should be tailored
based on an individual’s perceived ability to maintain the program. 1

In addition to cardiovascular and strengthening exercise, people with DM

should participate in a flexibility program. Peripheral neuropathy, as a
result of diabetes, may cause sensory and proprioceptive loss in the
extremities and decreased range of motion, specifically at the ankles,
feet, and shoulders. Zimny et al reported progressive stiffening of
collagen containing tissue in people with DM, which may add to joint
stiffness. This increased joint stiffness results in diminished range of
19

motion, but because the associated clinical disability is often subtle, it is

often overlooked. 19

Decreased range of motion in the ankle and foot may cause gait
abnormalities, such as a footflat contact or a forefoot contact gait
pattern. Either pattern eliminates the energy conserving and force
attenuating motion that occurs at the ankle and subtalar joint during a
normal gait cycle. Further, diminished metatarsophalangeal joint
dorsiflexion in the pre-swing phase of gait may result in decreased
balance and abnormal forefoot pressure. If MTP joint dorsiflexion is not
sufficient, the person may shorten their step length and exert more
energy to lift the leg from the support surface because a rigid lever for
push-off is not achieved. This gait pattern may increase susceptibility to
falls and injury. In addition to balance impairment, joint stiffness
throughout the foot may lead to increased midfoot and forefoot pressure
when walking. This can increase the risk of ulceration, particularly in
patients with peripheral neuropathy. This is supported by the findings of
20

Fernando et al, who reported that limitations in subtalar and first

metatarsophalangeal joint mobility resulted in increased peak foot
pressures during gait. 21

Foot and ankle exercises

Goldsmith et al found that persons with

DM who were educated in a foot and ankle exercise program experienced
decreased joint stiffness and decreased peak plantar pressure during gait
after only one month of intervention. The regimen included “drawing”
22

the alphabet with the foot (ABCs), passive and active dorsiflexion and
plantarflexion of the metatarsophalangeal joint, passive and active
dorsiflexion and plantarflexion of the ankles, active pronation and
supination of the subtalar joint, stretching of the gastrocnemius and
soleus, followed by soft tissue manipulation of the entire foot. Exercise
may improve joint stiffness and impact ulcer healing. Flahr evaluated the
effect on neuropathic foot wounds of non-weightbearing foot and ankle
exercises (including active inversion, eversion, dorsiflexion and
plantarflexion) performed 10 times each twice a day, and found that
those patients who participated in the exercise program trended toward
more rapid healing. Flahr attributed the healing to improved blood
supply in the area. 23

We performed a randomized, controlled study on the effect of a six-week

home exercise program, which focused on range of motion of the first
metatarsophalangeal joint and the talocural joint, on gait parameters in
persons with type 2 DM. Ten subjects participated in a home exercise
24

program (HEP) developed according to the American College of Sports

Medicine guidelines. The HEP consisted of a five to 10 minute warm-up
walk, ABCs, heel raises, toe raises, and towel exercises (dorsiflexion,
eversion, and inversion) to be performed three times per week for six
weeks. A difference in plantarflexion ROM was the only significant effect
of the exercise program for our population. No significant changes in gait
were noted. This may have resulted from the short duration of the
program.
Patients diagnosed with DM should be instructed in a home exercise
program that focuses on maintaining or improving range of motion in the
ankle and foot. Simply “drawing” an exaggerated alphabet with the ankle
twice daily; actively performing ankle dorsiflexion, plantarflexion,
inversion, eversion 10 times each twice daily; and manually mobilizing
the forefoot, including the first metatarsophalangeal joint, into
dorsiflexion will help to increase range of motion of the foot, diminish
peak foot pressure, and possibly prevent breakdown.
Balance exercises also should be incorporated into the daily exercise
regime of someone with diabetes. Wrobel and Najafi reported that people
25

with diabetes walk with “a conservative gait strategy” characterized by a

wider base of support and prolonged double support time. This gait
pattern may be a protective strategy to counter the effects of decreased
balance from diminished proprioception. For this reason, daily balance
exercises in a protected environment are recommended. Persons with
diabetes can be encouraged to maintain their balance by standing on one
foot while brushing their teeth or while washing the dishes. Balance
activities can be progressed to be more challenging, first by performing
dynamic activities such as raising the arms or catching a ball while
standing on a wide stable base of support with two feet on the ground,
then by performing the same activity with a progressively smaller base of
support, such as standing on one foot. Balance activities can be
progressed from a stable surface to unstable surfaces such as sand or a
dome while diminishing the base of support area.
Cognitive exercise is a relatively new area of study. Van Elderen et al
found increased progression of brain atrophy and decreased cognitive
function in patients with diabetes compared to normal
controls. Although data do not exist to support the benefits of cognitive
26

exercise in people with diabetes, initiating a cognitive exercise program

may help maintain cognitive function. Spending 30 minutes daily learning
a new skill, such as a foreign language or an instrument, or even doing
daily crossword puzzles or other brain teasers may help maintain or
improve cognitive function in people with diabetes.
Adherence to an exercise program is challenging for any individual,
independent of diabetes. Beverly and Wray reported that collective
27

support, motivation and responsibility all play a role in empowering an

individual to stick with an exercise program.
Lastly, before engaging in any exercise program, patients with diabetes
should consult a physician to ensure participation in such activity is safe.
Once the patient has been cleared to exercise, a physical therapist can
design an individualized program that incorporates the appropriate
exercises and focuses on the needs of the patient. Individuals with DM
must be cautioned to monitor blood glucose levels before, during, and
after exercise to avoid a hypoglycemic event during or after exercise as
well as a hyperglycemic event 24 hours post exercise. 2,16,17
As health care
providers, we must support and encourage exercise in our patients by
being role models and advocates.
DM is epidemic in the U.S. Maintaining health through exercise
decreases costs and improves quality of life. A preponderance of
28

evidence suggests that every person with DM should participate in a

consistent exercise program. We, as health care providers, must work
together to identify patients in need of guidance and direct them to the
appropriate practitioners who understand the potential complications
unique to this population.

Pamela D. Ritzline, PT, EdD, is associate professor and director of the

graduate program in the department of physical therapy at the
University of Tennessee Health Science Center in Memphis. Audrey
Zucker-Levin, PT, PhD is an associate professor in the same department.
References:
1. CDC National Diabetes Fact Sheet US, 2005. Available at:
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf
2. American Diabetes Association. Diabetes statistics. Available
at: http://www.diabetes.org/diabetes-basics/diabetes-statistics/
3. Mourot L, Boussuges A, Maunier S, et al. Cardiovascular rehabilitation
in patients with diabetes. J Cardiopulm Rehabil Prev 2010;30(3):157-164.
4. Pariser G, DeMeuro M,Gillette P, Stephen W. Outcomes of an
education and exercise program for adults with type 2 diabetes, and
comorbidities that limit their mobility: a preliminary project report.
Cardiopulm Phys Ther J 2010;21(2):5-12.
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muscle and body fat mass and muscle strength in type 2 diabetic women.
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