Diabetic Foot Remission: Essential Keys To Educating Patients On Dosing Activity And Returning To Pre-Ulcer Function

Here are the instructions we give our patients upon returning to prescriptive shoes/activity following the healing of a diabetic foot ulcer, foot reconstruction or partial foot amputation.

Emphasizing A Shoe Wear Schedule And Regular Foot Inspection

• After each trial of wearing the new shoes, immediately remove your shoes and socks and perform a foot inspection. Inspect the toes, top and bottom of foot, and look for any reddened areas or new areas of callus.

• If there is no redness or callus, proceed to increased wear time the next day. 

• If there is redness but it resolves in 15 minutes or less, proceed to increased wear time on the next day.

• If redness lasts longer than 15 minutes, do not increase the wear time and follow-up with the podiatrist, orthotist or your dispensing provider as adjustments may be necessary.

• Any new areas of callus need monitoring. Discuss this with your podiatrist and orthotist for regular care and orthotic/shoe modification. 

Establishing A Schedule For Returning To Activity

This return to activity schedule should not begin until the patient is up to eight hours or more wearing new custom footwear. The patient should definitely wear the custom footwear when he or she is being active.

• Use a fitness tracker (Fitbit, Garmin, Apple Watch, Samsung, etc.) or smartphone to track your daily steps.
• As long as you are using the same device consistently for tracking, you should be fine.
• If at any time, daily skin checks of your feet show prolonged redness (greater than 15 minutes), stay at that same daily step count (or decrease it slightly) until you no longer see the redness. Also consider that modifications may be necessary for your orthotics/shoes. 

Providing Counsel On Activities To (Potentially) Avoid

Some activities are likely to create significantly more shear and friction at the bottom of the foot. For patients with recently healed diabetic wounds, clinicians may want to counsel patients to avoid certain athletic activities and certain fitness equipment in order to prevent another wound. These pieces of equipment may include:

• elliptical machines;

• rowing machines;

• leg press; and

• treadmills.

While patients may use a treadmill intermittently, explain that walking regularly is preferable. Additionally, if a patient has a gym regimen that he or she would like to get back to, ask about this so you can make or suggest adjustments as necessary.

In addition to walking, strength training has very beneficial effects for diabetes management (blood sugar control, relief of neuropathy symptoms, overall improvement in function).¹

One can discuss these benefits with interested patients as well. 

Reminding Patients To Check Skin Temperature

Wounds often heat up before they break down. Remind patients that if they have a personal thermometer, they can dose their activity by checking their skin temperature just as they might dose their insulin by checking their glucose. At our institution, we also provide guidance to patients on how to map their foot for hot spots and communicate this with their podiatrists.

Dr. Armstrong is Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA). 

Editor’s Note: This blog originally appeared at: 

https://diabeticfootonline.com/2020/05/30/salsa-rancho-los-amigos-guidelines-for-return-to-activity-in-remission-toeflowandgo-usc-ranchoresearchi-usc_vascular/ . It is adapted with permission from the author.

Reference

1. Colberg SR, Sigal RJ, Yardley JE, et al. Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(11):2065-2079.