Preventing Foot Injuries In Diabetic Athletes

By Mark A. Caselli, DPM

Exercise plays an important role in the management of both insulin-dependent diabetes (IDDM) and non-insulin-dependent diabetes (NIDDM). Regular exercise, especially aerobic exercise, strengthens the heart and circulatory system, thus reducing the chance of heart disease and stroke. It helps decrease blood cholesterol and increases the levels of the “good” high-density lipoprotein (HDL) in the blood. Exercise lowers blood glucose levels, both during exercise and for several hours afterward. Walking is probably the best, safest and least expensive form of exercise. It can fit into almost anyone’s schedule and can be integrated into other events and activities. The only investment needed is a comfortable pair of appropriate shoes. However, many people prefer to jog or run. This yields a more intense workout in less time. It also can be associated with organized competitive activities such as marathons and often results in a much greater feeling of accomplishment and self-satisfaction. Unfortunately, running can lead to many types of foot and leg injuries. When it comes to the average recreational runner who trains regularly and takes occasional long distance runs, the injury rate is somewhere between 37 and 56 percent. One must recognize the factors that contribute to these injuries, especially when you’re treating diabetic athletes who are at increased risk. Fifty to 75 percent of all running injuries are from overuse injuries, which usually result in muscle strains, such as plantar fasciitis and shin splints. Some of the biomechanical factors, which can lead to these overuse injuries, include leg length discrepancy, flexibility problems, muscle weakness or imbalance and laxity of ligaments. Training errors are the most common cause of overuse injuries. Training errors include excess mileage, a change in training patterns, improper footwear or troubles with the training surfaces. In addition to these problems, the presence of diabetes also appears to result in the increased prevalence of pedal fractures in the athlete. A study comparing the incidence of pedal fractures in 60 diabetic athletes with 60 non-diabetic athletes revealed a two-fold increase in the number of diabetics sustaining fractures with the most frequently fractured bones being the second, third and fifth metatarsals. The diabetic athlete group also sustained more multiple foot fractures. What You Should Look For During The Exam The development and use of a foot management plan for the diabetic athlete can be an important tool in preventing foot injuries and serious lower extremity medical complications such as infections, ulcers and amputations. A thorough lower extremity evaluation of the diabetic athlete is an essential part of establishing a foot management plan. The evaluation should include a medical and sports (athletic activity) history. One should also be on the lookout for peripheral neuropathy, circulation compromise and any biomechanical abnormalities. A history of prior infections or ulcerations of the foot has important predictive value with regard to the potential for future ulcerations and other pedal complications. Each patient visit should include a thorough evaluation for peripheral neuropathy since neuropathy is the major component of nearly all diabetic ulcers. Using the Semmes-Weinstein 10-gram monofilament wire, you should take measurements at the following 10 sites: the first, third and fifth digits plantarly; the first, third and fifth metatarsal heads plantarly; the plantar midfoot both medially and laterally; the plantar heel; and the dorsum of the midfoot. When the athlete loses normal sensation, he or she fails to be aware of excessive plantar pressure. When it comes to treating patients with sensory neuropathy, you should identify and protect areas of potential excessive plantar pressure, such as a plantarflexed metatarsal. One should also consider the increased potential for foot fractures when the diabetic athlete has an insensate foot. Consider obtaining X-rays after the patient participates in any strenuous sports activity such as a marathon. You should schedule a follow-up exam in two to three weeks given the possibility of a stress fracture, which might not be evident on the initial X-rays. A follow-up X-ray at that time is strongly recommended, especially if there are associated findings such as localized swelling and deformity.

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