Open Access Highly Accessed Research article

Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: results of a randomized controlled trial

Cristina D Sartor1, Renata H Hasue1, Lícia P Cacciari1, Marco K Butugan1, Ricky Watari1, Anice C Pássaro1, Claudia Giacomozzi2 and Isabel CN Sacco1*

Author Affiliations

1 Physical Therapy, Speech and Occupational Therapy Dept, School of Medicine, University of São Paulo, 51, Cidade Universitária, São Paulo, SP, Brazil

2 Department of Technology and Health, Italian National Institute of Health, Rome, Italy

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BMC Musculoskeletal Disorders 2014, 15:137  doi:10.1186/1471-2474-15-137

Published: 27 April 2014



Foot musculoskeletal deficits are seldom addressed by preventive medicine despite their high prevalence in patients with diabetic polyneuropathy.

AIM: To investigate the effects of strengthening, stretching, and functional training on foot rollover process during gait.


A two-arm parallel-group randomized controlled trial with a blinded assessor was designed. Fifty-five patients diagnosed with diabetic polyneuropathy, 45 to 65 years-old were recruited. Exercises for foot-ankle and gait training were administered twice a week, for 12 weeks, to 26 patients assigned to the intervention group, while 29 patients assigned to control group received recommended standard medical care: pharmacological treatment for diabetes and foot care instructions. Both groups were assessed after 12 weeks, and the intervention group at follow-up (24 weeks). Primary outcomes involved foot rollover changes during gait, including peak pressure (PP). Secondary outcomes involved time-to-peak pressure (TPP) and pressure–time integral (PTI) in six foot-areas, mean center of pressure (COP) velocity, ankle kinematics and kinetics in the sagittal plane, intrinsic and extrinsic muscle function, and functional tests of foot and ankle.


Even though the intervention group primary outcome (PP) showed a not statistically significant change under the six foot areas, intention-to-treat comparisons yielded softening of heel strike (delayed heel TPP, p=.03), better eccentric control of forefoot contact (decrease in ankle extensor moment, p<.01; increase in function of ankle dorsiflexion, p<.05), earlier lateral forefoot contact with respect to medial forefoot (TPP anticipation, p<.01), and increased participation of hallux (increased PP and PTI, p=.03) and toes (increase in PTI, medium effect size). A slower COP mean velocity (p=.05), and an increase in overall foot and ankle function (p<.05) were also observed. In most cases, the values returned to baseline after the follow-up (p<.05).


Intervention discreetly changed foot rollover towards a more physiological process, supported by improved plantar pressure distribution and better functional condition of the foot ankle complex. Continuous monitoring of the foot status and patient education are necessary, and can contribute to preserving the integrity of foot muscles and joints impaired by polyneuropathy.

Trial registration Identifier: NCT01207284, registered in 20th September 2010.

Diabetic neuropathies; Rehabilitation; Exercise therapy; Walking; Randomized controlled trial; Foot; Ankle; Musculoskeletal manipulation