33-1 Managing and Monitoring the Physical Activity of Patients with Diabetic Foot Disease

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» Caring for the diabetic foot remains a monumental task for those entrusted with providing care to the lower extremities.

Caring for the diabetic foot remains a monumental task for those entrusted with providing care to the lower extremities. A confluence of numerous factors affect the health of the diabetic foot. Although there is certainly an association between diabetic foot disease and physical activity engagement, this relationship is nuanced and still not fully understood. While too much weightbearing activity can result in the formation of diabetic foot ulcers or prohibit healing, activity avoidance is clearly problematic for overall health and likely detrimental to maintaining resilience of the soft tissue of non-ulcerated diabetic feet. As such, there is likely a “Goldilocks” paradigm in place in which there is a level (or range) of physical activity that is “just right” for each person. This issue’s two audio lectures dive into the challenges of determining that just right dosage of activity for each patient. They also explore timely themes pertaining to the diabetic foot, including COVID-19 and the concept of maintaining activity-rich days for those patients in diabetic foot disease “remission.”

This issue’s commentaries present critical reviews of the latest literature pertaining to managing and monitoring physical activity profiles of patients with diabetic foot disease. In addition to considering the implications of the literature for care providers and patients, the contributors to this issue also address the larger ecosystem of healthcare by considering the role of healthcare payers in promoting lower extremity health. A sampling of the topics addressed by the original manuscripts reviewed by commentators includes: quantification of physical activity profiles, recommendations for managing physical activity levels, advances in offloading the diabetic foot to ensure safe participation in physical activity, and the use of foot temperature monitoring as an early warning system for times when physical activity should be dialed back.

It has been my great privilege to serve as the Guest Editor for this issue of Foot and Ankle Quarterly, and I am immensely grateful to my colleagues that kindly accepted the invitation to join me on this adventure. The international team that has come together for this issue is an all-star roster of clinicians and academics within the field of the diabetic foot. I hope you as a reader will come away from this issue better enabled to partner with patients in managing that “just right” level of physical activity engagement for each patient at each phase of their journey with diabetic foot disease.

Ryan T. Crews, PhD, CCRP

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Article Authors and Lecturers

  • David G. Armstrong, DPM, MD, PhD (n.)
  • Virginie Blanchette, DPM, PhD (1. Data Trace Publishing Company)
  • Ryan T. Crews, PhD, CCRP (1. Data Trace Publishing Company)
  • Frank L. Bowling, DPM (n.)
  • Joseph Candela, DPM (n.)
  • Annabelle L. Dookie, DPM (n.)
  • Malindu E. Fernando, MBBS, PhD (1. Data Trace Publishing Company)
  • Crystal Holmes, DPM (n.)
  • Patricia Kluding, DPM (1. Data Trace Publishing Company)
  • Peter A. Lazzarini, PhD (n.)
  • Brian D. Lepow, DPM (n.)
  • Chia-Ding Shih, DPM (n.)
  • Neil D. Reeves, DPM (n.)
  • Dyane E. Tower, DPM (n.)
  • James Wrobel, DPM (n.)

FAQ Journal Planning Committee

  • Chrissy Wesolowski (formally Calvert) (n.)
  • Kimberly Collignon (n.)
  • Lauren Molander (n.)
  • Stephanie Wu, DPM, MSc (n.)

33-1 Contributors

Guest Editor

Ryan T. Crews, PhD, CCRP
Dr. William M. Scholl College of Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University of Medicine and Science, Chicago, IL


David G. Armstrong, DPM, MD, PhD
Professor of Surgery, Co-Director, University of Southern California Limb Preservation Program, Los Angeles, CA; Director, Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine at the University of Southern California, Los Angeles, CA; Director, University of Southern California Center to Stream Healthcare in Place (C2Ship), Los Angeles, CA

Virginie Blanchette, DPM, MSc, PhD
Associate Professor, Podiatric Medicine Program, Université du Québec at Trois-Rivières (Canada), Board of Directors, Wounds Canada

Frank L. Bowling, BSc(Hons), PgD(Plast), MSc, DPM, PhD, DSc, FPRCPS, FRCPodS, FRCP
Professor of Surgery and Translational Medicine, University of Manchester, Manchester, UK; Consultant Podiatric Surgeon, Manchester Foundation Trust; Adjunct/Visiting Professor of Surgery, Victor Babes University of Medicine and Pharmacy, Timișoara, Romania and Nicolae Testemitanu University of Medicine and Pharmacy, Chișinău, Moldova; International Advisory Board, World Health Organization (WHO)

Joseph Candela, DPM, PhD
Staff Podiatrist, Department of Foot and Ankle Surgery, Major Health Partners, Shelbyville, IN

Annabelle L. Dookie, DPM, FACFAS
Assistant Professor, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine, Chicago, IL; Fellow, American College of Foot and Ankle Surgeons; Diplomate, American Board of Podiatric Medicine

Malindu (Mal) E. Fernando, PhD, MBBS, BHsc (podiatry) Hons
Visiting Fulbright scholar Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine of University of Southern California and at the Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Junior Doctor, The John Hunter Hospital, Newcastle, Australia; Adjunct post-doctoral research fellow, Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville, Australia; Conjoint Lecturer School of Medicine, University of Newcastle, Newcastle, Australia

Crystal Holmes, DPM, CWSP
Podiatry Program Director, University of Michigan Medical School, Ann Arbor, MI; Past President, Michigan Podiatric Medical Association

Patricia Kluding, PT, PhD
Professor and Chair, Department of Physical Therapy, Rehabilitation Science, and Athletic Training, Program Director, Doctor of Physical Therapy, University of Kansas Medical Center, Kansas City, KS

Peter A. Lazzarini, BAppSci, PhD
Associate Professor, School of Public Health and Social Work, Queensland University Technology, Brisbane, Australia; Principal Research Fellow, Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia; Secretary, Offloading Working Group, International Working Group on the Diabetic Foot

Brian D. Lepow, DPM
Assistant Professor of Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX

Chia-Ding (JD) Shih, DPM, MPH, MA
Assistant Professor, California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA

Neil D. Reeves, PhD
Professor of Musculoskeletal Biomechanics and Faculty Head of Research, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom

Director of Clinical Affairs and Senior Medical Director, American Podiatric Medical Association, Bethesda, MD

James Wrobel, DPM, MS
Staff Podiatrist, The Villages Health and University of Florida Health Central Florida, The Villages, FL

In This Issue

  • FEATURE ARTICLE: Physical Activity and the Diabetic Foot: Measuring What We Intend to Manage
    Ryan T. Crews, PhD, CCRP
    • Should Weightbearing Activity Be Reduced during Healing of Plantar Diabetic Foot Ulcers, Even when Using Appropriate Offloading Devices?
      Commentary by Neil D. Reeves, PhD
    • Lower Resource Utilization for Patients with Healed Diabetic Foot Ulcers during Participation in a Prevention Program with Foot Temperature Monitoring
      Commentary by James Wrobel, DPM
    • Mobility Advice to Help Prevent Re-Ulceration in Diabetes
      Commentary by Peter A. Lazzarini, PhD
    • Innovative Intelligent Insole System Reduces Diabetic Foot Ulcer Recurrence at Plantar Sites: A Prospective, Randomized, Proof-of-Concept Study
      Commentary by Dyane E. Tower, DPM
    • Short-Term Strength and Balance Training Does Not Improve Quality of Life but Improves Functional Status in Individuals with Diabetic Peripheral Neuropathy: A Randomized Controlled Trial
      Commentary by Annabelle L. Dookie, DPM
    • Moderate-to-Vigorous-Intensity Physical Activity Observed in People with Diabetes-Related Foot Ulcers over a One-Week Period
      Commentary by Joseph Candela, DPM, PhD
    • Ulcer-Free, Hospital-Free and Activity-Rich Days: Three Key Metrics for the Diabetic Foot in Remission
      Commentary by Crystal Holmes, DPM
    • Physical Training and Activity in People with Diabetic Peripheral Neuropathy: Paradigm Shift
      Commentary by Chia-Ding (JD) Shih, DPM, MPH, MA
    • Factors Associated with Wearing Inadequate Outdoor Footwear in Populations at Risk of Foot Ulceration: A Cross-Sectional Study
      Commentary by Brian D. Lepow, DPM
    • Heel-Rise and Non-Weightbearing Ankle Plantar Flexion Tasks to Assess Foot and Ankle Function in People with Diabetes Mellitus and Peripheral Neuropathy
      Commentary by Frank Bowling, DPM
  • AUDIO LECTURE 1: Physical Activity is Important for Those with Diabetic Peripheral Neuropathy
    Patricia Kluding, PT, PhD
  • AUDIO LECTURE 2: Excessive Physical Activity Engagement by Those with Diabetic Foot Disease is a Bigger Concern than Engaging in Too Little
    Malindu E. Fernando, MBBS, PhD, Virginie Blanchette, DPM, PhD and David G. Armstrong, DPM, MD, PhD