Diabetic peripheral neuropathy (DPN) is usually discussed in terms of what is lost: protective sensation, vibration perception, the ability to feel a stone in the shoe. Less often discussed is what else changes. Long before an ulcer appears, neuropathy quietly alters the musculoskeletal system of the foot — intrinsic muscles atrophy, the ankle and first metatarsophalangeal joint stiffen, toe function declines, and plantar load shifts toward the forefoot during walking. These are mechanical risk factors, and unlike sensory loss, several of them appear to be modifiable.
That premise underpins a growing body of research into foot-ankle therapeutic exercise: structured strengthening, mobility and functional training aimed specifically at the foot and ankle rather than at general fitness. The 2023 International Working Group on the Diabetic Foot (IWGDF) prevention guideline now addresses it directly.
What the Guidelines Say
In the 2023 IWGDF update on prevention of foot ulcers, Bus and colleagues issued a conditional recommendation: consider advising people with diabetes at low-to-moderate ulcer risk to undertake a foot-ankle exercise programme — preferably supervised — to reduce ulcer risk factors. The wording is deliberate. The recommendation targets risk factors, not ulceration itself, because no trial to date has been powered to show that foot-ankle exercise reduces ulcer incidence.
The same guideline addresses a related and frequently asked question about activity in general: an increase in total weight-bearing activity of approximately 1,000 steps per day is likely safe with respect to ulceration risk. This is a useful counterweight to the older instinct to restrict walking broadly in neuropathic patients, which carries its own costs in cardiovascular health, glycemic control and function.
What the Trials Show
The most informative evidence comes from a series of randomised controlled trials from the University of São Paulo. Monteiro and colleagues (Scientific Reports, 2022) randomised 78 people with DPN to usual care or usual care plus a 12-week supervised foot-ankle exercise programme. Adherence was high at 92.3%. Compared with usual care, the intervention group showed significant improvements at 12 weeks in fast gait speed, ankle range of motion, and vibration perception, with better quality of life at 24 weeks. Fast gait speed and vibration perception remained superior in the intervention arm at one year. Notably, daily step count and self-selected gait speed did not change — the benefit was in capacity and joint function rather than in habitual activity volume.
An earlier feasibility RCT by the same group (Monteiro et al., Sensors, 2020) reported improved toe strength, altered contact time during gait, and reduced neuropathy symptoms in the exercise arm, with 80% programme adherence and high participant satisfaction.
Pooled Evidence on Mechanics
Lepesis and colleagues (Diabetes/Metabolism Research and Reviews, 2023) conducted a systematic review and meta-analysis of foot and ankle physical therapy — mobilisations, range-of-motion work and stretching — in people with diabetes and neuropathy. Pooling three studies, combined exercise interventions significantly increased total ankle range of motion (mean difference 1.76°; 95% CI 0.78–2.74). A pooled reduction in forefoot peak plantar pressure was observed but did not reach statistical significance (MD −23.34 kPa; 95% CI −59.80 to 13.13), with moderate heterogeneity. The authors noted wide variation in exercise type and dosage across studies and called for standardised protocols.
Delivery Matters — and Has Limits
Access is a practical barrier to supervised programmes. Ferreira and colleagues (Scientific Reports, 2024) tested a 12-week web-based foot-ankle exercise programme (the SOPeD software) against usual care in 62 participants with DPN. The programme was feasible, acceptable and safe, with adverse events limited to delayed-onset muscle soreness and foot cramping. However, the primary outcomes — DPN symptoms and severity — were unchanged. Secondary gains included better foot function, reduced foot pain, greater functional reach and increased plantarflexion at push-off, mostly emerging at 24 weeks. The trajectory suggests benefit may accrue slowly and that remote delivery, while scalable, may be less potent than supervised training.
Clinical Summary
Foot-ankle exercise therapy has a modest but consistent evidence base for improving joint mobility, foot strength, gait speed, foot pain and function in diabetic peripheral neuropathy. Effects on neuropathy severity itself are inconsistent, and effects on plantar pressure are smaller and less certain than early mechanistic reasoning predicted. Critically, no trial has demonstrated a reduction in ulcer incidence, which is why the IWGDF recommendation remains conditional and is directed at lower-risk patients rather than those with active or recently healed ulceration. Adverse events across trials have been minor, and adherence has generally been good. The evidence supports foot-ankle exercise as a reasonable adjunct to — never a substitute for — screening, pressure-relieving therapeutic footwear, education and integrated foot care.
References
- Bus SA, Sacco ICN, Monteiro-Soares M, Raspovic A, Paton J, Rasmussen A, Lavery LA, van Netten JJ. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3651.
- van Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M, Paton J, Rasmussen A, Sacco ICN, Bus SA. Prevention of foot ulcers in persons with diabetes at risk of ulceration: A systematic review and meta-analysis. Diabetes/Metabolism Research and Reviews. 2024;40(3):e3652.
- Monteiro RL, Ferreira JSSP, Silva ÉQ, Cruvinel-Júnior RH, Veríssimo JL, Bus SA, Sacco ICN. Foot-ankle therapeutic exercise program can improve gait speed in people with diabetic neuropathy: a randomized controlled trial. Scientific Reports. 2022;12(1):7561.
- Lepesis V, Marsden J, Rickard A, Latour JM, Paton J. Systematic review and meta-analysis of the effects of foot and ankle physical therapy, including mobilisations and exercises, in people with diabetic peripheral neuropathy on range of motion, peak plantar pressures and balance. Diabetes/Metabolism Research and Reviews. 2023;39(8):e3692.
- Ferreira JSSP, Cruvinel-Júnior RH, da Silva EQ, Veríssimo JL, Monteiro RL, Duarte M, Giacomozzi C, Sacco ICN. Effectiveness of a web-based foot-ankle exercise program for treating ulcer risk factors in diabetic neuropathy in a randomized controlled trial. Scientific Reports. 2024;14(1):27291.
- Monteiro RL, Ferreira JSSP, Silva ÉQ, Donini A, Cruvinel-Júnior RH, Veríssimo JL, Bus SA, Sacco ICN. Feasibility and preliminary efficacy of a foot-ankle exercise program aiming to improve foot-ankle functionality and gait biomechanics in people with diabetic neuropathy: a randomized controlled trial. Sensors. 2020;20(18):5129.
Comments
