Regular physical activity improves glycemic control, cardiovascular fitness, and mortality in people with diabetes, yet people with diabetic peripheral neuropathy have long been advised to limit walking out of concern for plantar ulceration. Because loss of protective sensation means repetitive mechanical stress can go unnoticed, the question of how much weight-bearing activity is safe has real clinical weight. Recent trials, systematic reviews, and the 2023 International Working Group on the Diabetic Foot (IWGDF) prevention guideline now offer a more nuanced answer.
Plantar Tissue Stress: Why Activity Is Not Simply “Good” or “Bad”
Ulceration results from the accumulation of mechanical stress over time rather than from a single step. Lazzarini and colleagues (2019) described plantar tissue stress as the accumulation of all mechanical stresses on an area of plantar tissue from weight-bearing activity over time. Under this model, risk reflects both the magnitude of pressure and the amount of loading, which is influenced by footwear, deformity, and adherence to offloading.
The same review noted that people with neuropathy spend roughly twice as much time standing as walking, and that findings linking activity patterns to ulcer development are inconsistent. An earlier study by Maluf and Mueller found that people with a history of ulceration had lower forefoot stress than controls, which the authors linked to possible deconditioning. Lazzarini et al. also raised the possibility that regular, gradually increased weight-bearing may build tissue tolerance, although this remains a hypothesis requiring further research.
How Active Are People With Diabetes-Related Foot Disease?
A systematic review by Fernando, Armstrong, and colleagues (2022) included 27 studies drawn from 1,247 screened publications. Mean daily step counts were similar across IWGDF risk strata: about 6,125 steps per day for risk categories 1 and 2 and 6,275 for category 3. People with an active foot ulcer were less active, averaging approximately 4,248 steps per day. Participants were also more active indoors than outdoors, and activity varied with climate. These figures give clinicians reference points, and they show that people at higher risk are not necessarily less active until an ulcer is present.
Does Weight-Bearing Exercise Increase Ulcer Risk?
The Feet First randomized controlled trial (LeMaster et al., Physical Therapy, 2008) enrolled 79 people with diabetic peripheral neuropathy. The intervention group (n=41) received leg strengthening, balance exercises, and a graduated walking program; the control group (n=38) received standard care. Over 12 months, foot ulcer rates did not differ significantly between groups, suggesting that a supervised, graduated program with appropriate footwear did not measurably increase ulceration in people without a current ulcer.
The IWGDF 2023 prevention guideline (Bus et al., Diabetes/Metabolism Research and Reviews, 2024) reflects this evidence. For people at low-to-moderate risk, it suggests considering a foot-ankle exercise program, preferably supervised, to reduce ulcer risk factors, and notes that a total increase of about 1,000 steps per day in weight-bearing activity is likely safe with respect to ulcer risk. These are conditional suggestions that apply to specific risk groups rather than blanket endorsements.
Exercise in the Presence of an Ulcer
Evidence for exercise as a means of improving healing is limited. Tran and Haley (2021) systematically reviewed three randomized trials involving 139 participants, all testing non-weight-bearing exercise over 12 weeks. Two trials reported greater wound size reduction with exercise, but only the supervised study reached statistical significance (94.08% versus 54.76% reduction, p < 0.05). The home-based trial showed no significant difference, and adherence to unsupervised programs was difficult to verify. Methodological quality was moderate, and the authors concluded there was insufficient evidence to support exercise as a healing intervention, while noting that no meaningful harm was observed and that non-weight-bearing exercise could reasonably be encouraged under professional guidance.
Conclusion
Current evidence indicates that moderate, graduated weight-bearing activity does not appear to raise ulcer rates in people with neuropathy who have no active ulcer, provided footwear is appropriate and activity is supervised. Plantar tissue stress is better understood as a product of load, repetition, footwear, and adherence than of activity alone. Ulcer risk status should guide recommendations, with more conservative advice for those with active wounds or higher-risk feet. Data on exercise and ulcer healing remain sparse, and larger supervised trials are needed.
References
- Bus SA, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3651.
- Fernando ME, Woelfel SL, Perry D, Najafi B, Khan T, DuBourdieu C, Shin L, Armstrong DG. Weight-bearing physical activity in people with diabetes-related foot disease: a systematic review. 2022 (DOI 10.7547/20-166).
- Lazzarini PA, Crews RT, van Netten JJ, Bus SA, Fernando ME, Chadwick PJ, Najafi B. Measuring plantar tissue stress in people with diabetic peripheral neuropathy: a critical concept in diabetic foot management. Journal of Diabetes Science and Technology. 2019;13(5):869-880.
- LeMaster JW, Mueller MJ, Reiber GE, Mehr DR, Madsen RW, Conn VS. Effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: Feet First randomized controlled trial. Physical Therapy. 2008;88(11):1385-1398.
- Tran MM, Haley MN. Does exercise improve healing of diabetic foot ulcers? A systematic review. Journal of Foot and Ankle Research. 2021;14:19.
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