Journal of the American Podiatric Medical Association • Vol 92 • No 9 • October 2002483
Cutaneous ulceration is one of the most serious se-
quelae that can occur in the diabetic foot. Unre-
solved, a diabetic foot ulceration may eventually lead
to lower-extremity amputation.1, 2Insensitivity, dehy-
drated integument, limited joint mobility, and repeti-
The Effects of Range-of-Motion
Therapy on the Plantar Pressures
of Patients with Diabetes Mellitus
Jon R. Goldsmith, BS*
Roy H. Lidtke, DPM, CPed†
Susan Shott, PhD‡
A randomized controlled study of 19 patients with diabetes mellitus (10
men, 9 women) was undertaken to determine the effects of home exer-
cise therapy on joint mobility and plantar pressures. Of the 19 subjects,
9 subjects performed unsupervised active and passive range-of-motion
exercises of the joints in their feet. Each subject was evaluated for joint
stiffness and peak plantar pressures at the beginning and conclusion of
the study. After only 1 month of therapy, a statistically significant aver-
age decrease of 4.2% in peak plantar pressures was noted in the sub-
jects performing the range-of-motion exercises. In the control group, an
average increase of 4.4% in peak plantar pressures was noted. Although
the joint mobility data revealed no statistically significant differences be-
tween the groups, there was a trend for a decrease in joint stiffness in
the treatment group. The results of this study demonstrate that an unsu-
pervised range-of-motion exercise program can reduce peak plantar
pressures in the diabetic foot. Given that high plantar pressures have
been linked to diabetic neuropathic ulceration, it may be possible to re-
duce the risk of such ulceration with this therapy. (J Am Podiatr Med
Assoc 92(9): 483-490, 2002)
*Submitted during third year, Dr. William M. Scholl Col-
lege of Podiatric Medicine at Finch University, Chicago, IL.
†Director of the Gait Analysis Laboratory, Acting Direc-
tor of Research, and Assistant Professor of Orthopedics, Dr.
William M. Scholl College of Podiatric Medicine at Finch
University, Chicago, IL; Visiting Professor, Department of
Orthopedic Surgery, Rush-Presbyterian-St. Lukes Medical
Center, Chicago, IL. Mailing address: Dr. William M. Scholl
College of Podiatric Medicine at Finch University, 1001 N
Dearborn St, Chicago, IL 60610.
‡Assistant Professor, Department of Preventative Medi-
cine, Rush-Presbyterian-St. Lukes Medical Center, Chicago,
2002 WILLIAM J. STICKEL SILVER AWARD
tive pressures have been suggested to contribute to
dermal pathology and eventual ulceration.3-11This
study focused on reducing limited joint mobility and
the corresponding changes in peak plantar pressures
in the diabetic foot.
Limited joint mobility has been found to be a com-
mon complication of diabetes mellitus. It has been
reported to be present in up to 30% of children with
type 1 diabetes12, 13and in up to 45% of adults with
type 2 diabetes.14The etiology of limited joint mobili-
ty has been described as an increase in the nonenzy-
matic glycosylation of collagen that leads to a thick-
ening of various soft-tissue structures.15, 16Limited
joint mobility has been associated with a variety of
systemic pathologies such as hypertension and pe-
ripheral neuropathy.17Some studies of upper
484 October 2002 • Vol 92 • No 9 • Journal of the American Podiatric Medical Association
extremity joints have suggested that the inability
to approximate the palmar surfaces, or to make the
“prayer” sign, demonstrates significant limited joint
mobility in all joints (Fig. 1).12, 13It is clear that limit-
ed joint mobility constitutes a significant biomechan-
ical abnormality when it affects the joints of the
lower extremity. For example, if a reduction in flexi-
bility were present at the first metatarsophalangeal
joint during propulsion, one would expect an alter-
ation in forefoot pressures. Indeed, the presence of
limited joint motion in the foot has been shown to re-
sult in increased plantar pressures, which may lead
to ulceration in the presence of comorbidities such
as neuropathy.3, 4, 18-25
Currently, there is little information available on
the treatment of high peak plantar pressures in con-
junction with limited joint mobility. Studies have sug-
gested that any treatment protocol for neuropathic ul-
ceration must address the increased plantar pressures
by off-loading weight in the area or reducing plantar
pressures by another method such as combined thera-
py, bracing, or even surgery.5, 6, 8, 24, 26-29It has been de-
termined that limited joint motion significantly in-
creases plantar pressures in subjects with diabetes
mellitus.21, 30, 31One preliminary study determined
that several months of scheduled visits with a physi-
cal therapist trained in passive range-of-motion exer-
cises resulted in a significant increase in the range of
motion of joints in the feet of neuropathic diabetic
subjects compared with a nondiabetic control group.32
As the health-care system is already overburdened
and is currently devoting $98 billion annually to dia-
betes care, the provision of this specialized therapy
is not realistic for the 17 million diabetic patients in
the United States today.33
The purpose of this randomized controlled study
was to determine the effect of unsupervised active
and passive range-of-motion exercises on plantar
pressures in subjects with diabetes. The authors hy-
pothesized that after performing these exercises,
subjects would demonstrate an increase in the mobil-
ity of the joints in their feet and a decrease in peak
Materials and Methods
Twenty-one diabetic subjects were referred from
Northwestern University Medical Center in Chicago, Il-
linois. Subjects were required to have a history of di-
abetes mellitus and no history of pedal ulceration.
Exclusion criteria included pedal amputations and
arthritides. Subjects who were pregnant, who had
been diagnosed with generalized osteoporosis, or
who had fractures of any bones in the lower extremity
were excluded. Moreover, subjects displaying gross
musculoskeletal problems or significant scar tissue or
calluses on the feet were excluded from the project.
Participating subjects were required to be able to
walk 10 m unassisted.
Subjects were assigned to either a treatment group
or a control group by computer randomization. Each
treatment group and control group subject agreed to
follow the standard instructions given to each group
and signed an informed consent form that had been
approved by the university institutional review board.
A single, trained investigator evaluated all subjects
and collected all data to eliminate interinvestigator
error. During the initial visit, the subjects received
study information and instructions. Subject health
status, age, sex, race, medications, type of diabetes,
duration of diabetes, frequency of checking blood
glucose level, last serum glucose level reading, and
results of last hemoglobin A1c (HbA1c) examination
were obtained and recorded. The following clinical
findings were collected from each subject: ability to
sense a 5.07 and 6.10 Semmes-Weinstein monofila-
ment on the ten locations of the foot as described by
the Gillis W. Long Hansen’s Disease Institution,34
length of time subjects were able to sense a vibrating
128-Hz tuning fork, strength of pedal pulses (dorsalis
pedis and posterior tibial pulses) on a scale of 0 to 4,
and cutaneous temperatures at the plantar aspect of
the distal phalanx of the hallux, plantar aspect of the
first metatarsophalangeal joint, and plantar aspect of
the calcaneus using digital thermography.
The dominant foot was determined by asking the
subject to kick a ball. The foot used was deemed
dominant, and this information was recorded.
Limited joint mobility was assessed by 1) the sub-
Figure 1. The “prayer” sign demonstrates the inability
of the patient to approximate the palmar surfaces of
Journal of the American Podiatric Medical Association • Vol 92 • No 9 • October 2002485
ject’s ability to demonstrate the upper-extremity
“prayer” sign, 2) the extent of ankle range of motion,
and 3) the extent of first metatarsophalangeal joint
range of motion. Subjects demonstrating limited joint
mobility due to a bony block were excluded from the
In order to ensure neutral positioning for the data
collection, the lower extremities of each subject from
both groups were examined by placing the lower ex-
tremity in a standardized jig (Fig. 2). A twin-axis digi-
tal goniometer (SG65, Biometrics Ltd, Cwmfelinfach,
United Kingdom) and force transducer (BG50, Mark-
10 Corp, Hicksville, New York) were used to deter-
mine joint range of motion. To measure the range of
motion at both the ankle and the first metatarsopha-
langeal joint, the goniometer was placed across the
joint’s axis. In separate trials, force was applied across
the plantar aspect of the metatarsal heads to mea-
sure range of motion at the ankle, and across the
plantar aspect of the hallux interphalangeal joint to
examine the range of motion at the first metatarso-
phalangeal joint (Fig. 3). In both cases, the force
transducer was kept orthogonal to the joint axis. The
joint rotation angles and applied force were simulta-
neously recorded using the LabVIEW software pro-
gram and PCI-6030E analog to digital card sampling
at 250 Hz (National Instruments Corp, Austin, Texas).
Plantar pedal pressures of each subject were re-
corded using the Musgrave Footprint System (Mus-
grave Systems Ltd, Llangollen, United Kingdom) (Figs.
4 and 5). Subjects were asked to walk barefoot “at a
comfortable pace” and data were collected using a
midgait method. Six separate trials were conducted.
Each trial was required to be within 50 msec of the
mean duration of the stance phase for each subject.
The position of the plates was noted and the distance
from sensor 1 of plate A to sensor 1 of plate B was
used to calculate step length and walking speed.
Subjects assigned to the control group were ad-
vised to continue their prestudy lifestyle. A single in-
vestigator instructed those in the treatment group in
how to perform the therapeutic exercises. The inves-
tigator demonstrated the proper way to perform the
exercises, and each study subject was required to
demonstrate the proper technique. Each subject re-
ceived an exercise manual and a standardized video-
tape produced by the investigators that demonstrated
the methodology for performing the exercises. The
therapy program is outlined in Table 1. The treatment
group subjects were instructed to perform the exer-
cises up to three times per day. Subjects were re-
Figure 2. Setup of the apparatus used to collect ankle
force and angle data.
Figure 4. Patients walked barefoot across pressure
plates before and after the therapeutic intervention.
Figure 3. Setup of the apparatus used to measure
stiffness of the first metatarsophalangeal joint.
486 October 2002 • Vol 92 • No 9 • Journal of the American Podiatric Medical Association
quired to document the amount of physical therapy
completed each day and were contacted on a weekly
basis to review any relevant findings from the previ-
ous week of exercising. All complications and per-
ceived benefits were noted.
The second visit was scheduled approximately 4
weeks after the initial visit. At this visit, the medical
history was reviewed and any changes were docu-
mented. The physical activity for the month was as-
sessed to ensure the integrity of the study. Neurovas-
cular parameters, plantar pressures, and joint range
of motion were remeasured and recorded using the
previously described methods.
Range-of-motion data were filtered using a low-pass
filter in a SigmaStat software program (SPSS Sci-
ence, Chicago, Illinois). A stress-strain curve was ob-
tained by plotting the range-of-motion data against
the applied force data (Fig. 6). From these data, a
simple joint stiffness value was determined by divid-
ing the force by the corresponding displacement with-
in the elastic region of the load-displacement curve.
The elastic modulus (Young’s modulus) was calculat-
ed using the ratio of stress to strain for the linear por-
tion of the load-displacement curve. This ratio for the
resultant curve was plotted on a graph and a con-
stant modulus was observed for each joint (Fig. 7).
This constant integral was evaluated at each joint, at
the beginning and at the conclusion of the study, for
both dominant and nondominant feet. The plantar
pressures of all trials during each session were aver-
aged, and the peak plantar pressures for 0% to 20%,
21% to 50%, 51% to 80%, and 81% to 100% of the gait
cycle were obtained.
SPSS for Windows, version 10 (SPSS Science) was
used for statistical analysis and data management.
Weight, body-mass index, HbA1c, and the average
number of exercise sessions performed per day were
examined for statistically significant differences be-
tween the control and treatment groups using the
nonparametric Mann-Whitney test. Sex, race, domi-
Figure 5. Representative three-dimensional plot of
the plantar pressure data.
Table 1. Outline of the Exercise Program
Draw the alphabet using the hallux, bilaterally
Stretching Exercises (5 sets each)
1. Passive dorsiflexion and plantarflexion of the metatarso-
phalangeal joints, holding each direction for 10 sec
2. Active dorsiflexion and plantarflexion of the metatarso-
phalangeal joints, holding each direction for 10 sec
3. Seated passive dorsiflexion and plantarflexion with appli-
cation of partial body weight at the metatarsophalangeal
joints, holding each direction for 10 sec
4. Active dorsiflexion and plantarflexion of the ankles, hold-
ing each direction for 10 sec
5. Active supination and pronation of the subtalar joints,
holding each direction for 10 sec
6. Standing gastrocnemius stretch, holding for 10 sec
7. Standing soleal stretch, holding for 10 sec
Soft-tissue manipulation, 30 sec at the forefoot, midfoot,
rearfoot, and posterior aspect of the distal one-third of the
Figure 6. Force versus displacement plot for the right
ankle of subject 13. The unevenness is probably due
to the subject “assisting” in the motion and oversam-
–10 0 10 20
Journal of the American Podiatric Medical Association • Vol 92 • No 9 • October 2002487
nant foot, type of diabetes, and positive “prayer” sign
were examined for statistically significant differ-
ences between the groups using Fisher’s exact test.
Pooled-variance and separate-variance t-tests were
used to determine any statistically significant differ-
ences with regard to age, duration of diabetes, and
days between study sessions. The nonparametric
Friedman test was performed separately for each
group to investigate differences between pretreat-
ment and post-treatment measures for non-nominal
variables that did not have statistically normal distri-
butions such as grades for pedal pulses, Semmes-
Weinstein measurements, and Young’s modulus. For
variables with statistically normal distributions—
plantar pressure, cutaneous temperature, and vibra-
tion sensation—three-factor repeated-measures anal-
ysis of variance (ANOVA) was performed, with the
within-subjects factor time (pretreatment and post-
treatment) and two between-subjects factors, group
(control and treatment group) and sex (women and
men). Data for the dominant and nondominant feet
were analyzed separately using Friedman tests and
Nine subjects completed the range-of-motion therapy
program, with two lost to follow-up. Ten control sub-
jects completed the study. There were no statistically
significant differences between the treatment and
control groups with regard to age, sex, duration of di-
abetes, type of diabetes, HbA1c scores, body-mass
index, weight, time between initial and concluding
visits, ability to perform the “prayer” sign, ability to
sense vibration, or ability to detect the Semmes-We-
instein monofilament (5.07 and 6.10).
Joint stiffness as determined by Young’s modulus
showed a trend for a decrease in stiffness in the treat-
ment group, especially in the dominant foot. A stiffer
joint requires greater force for a corresponding dis-
placement; thus the slope of the curve would be high-
er. As the patients gained more flexibility, the joint
would be more lax, and less force would produce
more motion; thus there would be a reduction in the
slope of the curve and therefore in the elastic modu-
lus. There appeared to be a corresponding trend for
increased stiffness in the control subjects (Figs. 8 and
9); however, the difference was not statistically sig-
nificant (P < .05). Further investigation is required.
Peak plantar pressures decreased an average of
4.2% for each period of the gait cycle in the treatment
group, while they increased an average of 4.4% for
each period of the gait cycle in the control group.
The results of each period are shown in Figures 10
through 13. There was a statistically significant dif-
ference (P = .024) between the control and treatment
groups during 0% to 20% of the gait cycle for the
dominant foot. Statistical significance (P = .049) was
also reached during 81% to 100% of the gait cycle for
the nondominant foot.
Three treatment subjects felt more flexibility in
their feet, and one subject described her Achilles ten-
don as being “looser.” Three treatment subjects de-
scribed the exercises as feeling good. Two treatment
subjects felt that the exercise program demanded too
much time per day. One treatment subject felt sore
after the first day of exercises, and two subjects said
they would continue the exercise program on con-
clusion of the study.
The physiologic manifestations of diabetes are ex-
tremely variable and can be influenced by many fac-
tors. No statistically significant differences in terms
of patient demographics were noted between the con-
trol and treatment groups in this study. There were
no statistically significant differences in cutaneous
temperature within and between groups at onset and
conclusion of the study. It is therefore unlikely that
temperature affected the elasticity of the soft tissues
during data collection. It is also unlikely that changes
in neurologic status contributed to alterations in
pressure and joint stiffness, as the neurologic tests
performed on the subjects showed no statistically sig-
nificant differences within or between study groups
Figure 7. Plot of the elastic modulus for the right ankle
joint of subject 8. The initial part of the graph repre-
sents the nonlinear portion of the stress-strain curve.
Note how the plot settles to a near constant variable
representing Young’s modulus in the linear portion of
the stress-strain curve.
488 October 2002 • Vol 92 • No 9 • Journal of the American Podiatric Medical Association
between observations. It may have been possible to
use a more sensitive neurologic test such as two-
point discrimination with pressure transducers, but
the authors believe that the length of time a subject
can sense a vibrating 128-Hz tuning fork is a very sen-
sitive and reliable indicator of the level of neuropathy.
The flexibility data showed a trend for an increase
in flexibility at the first metatarsophalangeal joint
and ankle joint after performing this exercise pro-
gram. These data were inconclusive because the dif-
Figure 8. Ankle joint stiffness (elastic modulus). Note
the large reduction in stiffness after treatment for the
dominant foot and the increase in stiffness for the con-
Figure 9. First metatarsophalangeal joint stiffness (elas-
tic modulus). As for the ankle joint, the dominant foot
demonstrated the greatest differences between the
treatment and control groups.
0–20% 21–50% 51–80%81–100%
Figure 10. Dominant foot plantar pressures in the
control group. Note the increase in pressure after 1
month, with the greatest pressures during the propul-
sive phases of the gait cycle.
Period of Gait Cycle
Period of Gait Cycle
Figure 11. Dominant foot plantar pressures in the
treatment group. The greatest changes occurred at the
initial loading response and during the propulsive
phases of the gait cycle. This may be due to the fact
that the exercises focused on the ankle and first
metatarsophalangeal joints, which may be more ac-
tive during these periods.
Journal of the American Podiatric Medical Association • Vol 92 • No 9 • October 2002489
ference did not reach statistical significance; however,
a larger sample size may have resulted in statistical
significance. The decision to break the subjects down
into dominant and nondominant feet instead of com-
bining right and left feet into one group effectively re-
duced the data set. The authors feel strongly that all
lower-extremity data should be broken down into
dominant and nondominant sets rather than broken
down into right feet and left feet or, worse yet, com-
bining the data into a data set comprising both right
and left feet on the assumption that both sides be-
have similarly. The authors’ data indicate that the
dominant foot responds faster and to a greater ex-
tent to therapeutic intervention than the nondomi-
nant foot (Figs. 10–13).
Another possible limitation of these data was an
error in collection due to oversampling. The joint
was moved at a frequency of close to 1 Hz. An appro-
priate sampling rate would have been ten times the
naturally occurring frequency (Nyquist frequency),
or 10 Hz in this case. An error during the initial pro-
gramming in LabVIEW set the sampling rate to 250
Hz, leading to oversampling. This produced large
amounts of data that had to be excessively smoothed
to produce a usable data set.
The plantar pressure data indicate that subjects
who perform a relatively simple active and passive
range-of-motion exercise program for 1 month can
significantly lower their peak plantar pressures. Sta-
tistical significance was not reached at every period
of the gait cycle for dominant and nondominant feet.
It should be noted that there were not significant re-
ductions in plantar pressures during the middle period
of the gait cycle (21–80%). The greatest change in
plantar pressure was observed from heel contact (0%)
to 20% and again at terminal stance from 81% to toe-
off (100%). It is possible that the joints of the foot that
the therapy focused on are utilized to a greater extent
during these parts of the gait cycle, resulting in a
greater influence on plantar pressures during these
periods (Figs. 11 and 13). Alternatively, the variation
may be due to the small sample size of the study. It is
important to note that the study consisted of only 1
month of exercise and that, with a greater study du-
ration, a more significant reduction in pressure might
have been achieved. Another limiting factor of this
study was the health of this diabetic population,
whose illness was well controlled. This population
was expressly chosen by the authors in an attempt to
avoid any harm to the subjects from the exercise pro-
gram. A population whose diabetes was less well
controlled and that was more affected by limited
joint mobility might demonstrate a greater reduction
in peak plantar pressures with the use of this exer-
Future studies should address the limitations of
this study and focus on creating an optimal exercise
program to increase joint mobility and reduce plan-
tar pressures in diabetic subjects.
The results of this study demonstrate that an unsu-
pervised range-of-motion exercise program can sig-
Figure 12. Nondominant foot plantar pressures in the
control group. Note the lower heel-strike pressures in
the nondominant foot as compared with the dominant
foot (Fig. 10).
0–20% 21–50%51–80% 81–100%
Period of Gait Cycle
Figure 13. Nondominant foot plantar pressures in the
treatment group. The change in the nondominant foot
was not as large as in the dominant foot (Fig. 11).
0–20% 21–50%51–80% 81–100%
Period of Gait Cycle
490October 2002 • Vol 92 • No 9 • Journal of the American Podiatric Medical Association Download full-text
nificantly reduce peak plantar pressures in diabetic
subjects within a relatively short period of time. It is
possible that a simple home exercise program for di-
abetic patients could result in fewer ulcerations of
the plantar aspect of the foot. Given the complex na-
ture of this disease and the enormous cost associat-
ed with current treatments, clinicians and patients
alike should be searching out such therapies and be
willing to implement them to assist in the treatment of
Acknowledgment. David S. Oyer, MD, of North-
western University in Chicago, Illinois, for his project
protocol suggestions and his participation in the re-
cruitment of subjects for the study; Julie-Kate Wade-
Webster, DPM, for her early work; and Jim West for
assistance in production of the standardized exercise
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