Limited foot Joint Mobility
The relationship between diabetes and limited joint mobility has generated much research in recent times and yet much is still unknown about this phenomenon. The common theory is that the process of glycosylation causes stiffening of collagen in joint capsules leading to the restricted range of motion seen clinically. The foot joints most commonly affected by limited joint range of motion are the ankle joint and the first metatarsophalangeal joint. While some researchers indicate that a positive prayer sign is indicative of limited joint range of motion in the feet, this association is yet to be confirmed by large-scale, high-quality research. As such, the following discussion will not rely on the prayer sign but rather evaluate both the ankle and the first metatarsophalangeal joint range of motion as separate entities.This decision relies on the principle that there may be people who have a pre- existing ankle equinus or first ray pathomechanics which are independent to diabetes-induced limited joint range of motion. By relying on the prayer sign alone to determine limited joint range of motion, biomechanical abnormality in the forefoot, unrelated to the effects of glycosylation, may fail to be detected and corrected
Normal range of motion for the ankle joint is 100 of dorsiflexion. This range of motion is necessary to enable normal heel-to-toe function during gait. The primary treatment modality in patients with less than 100 of dorsiflexion is stretching of the posterior leg muscles. Stretching in the neuropathic patient must be carried out with caution and where possible the therapy should be conservative and carried out under supervision. The neuropathic patient is at greater risk of injury due to the lack of sensory feedback and may be at risk of tendon injury or joint disruption. Acupuncture or dry needling of the posterior leg muscles has been shown to relax the muscles prior to stretch and may prove of some benefit to patients with very tight posterior leg muscles. Surgical intervention in the form of a tendon-lengthening procedure is indicated in extreme cases where there is evidence of a shortened Achilles tendon and conservative therapy has failed. Surgical intervention may also be indicated in cases where a tight posterior muscle complex is believed to be the prima cause of plantar forefoot ulceration and where conservative therapy has failed.
Normal range of motion for the first metatarsophalangeal joint is greater than 500 of dorsiflexion during non weight bearing and greater than 120 of dorsiflexion during weight bearing. Adequate first metatarsophalangeal joint dorsiflexion is necessary to allow the heel to lift during the propulsive phase of gait. Inadequate first metatarsophalangeal joint dorsiflexion will cause joint destruction and potentially increase the risk of Charcot arthropathy. Clinical signs of limited joint range of motion in the first metatarsophalangeal joint include dorsal exostosis over the joint, hyperextended (dorsiflexed) hallux (first toe), and callus over the medial, plantar aspect of the hallux (first toe) as well as beneath the second to fifth metatarsophalangeal joints. Treatment for restricted range of motion in the first metatarsophalangeal joint is directed toward functional immobilization of the first metatarsophalangeal joint and joint manipulation to increase joint range of motion. Joint manipulation is a specialized area and will not be discussed here as this therapy should be carried out by skilled professionals. Immobilization of the first metatarsophalangeal joint can be achieved by using a rocker-sole under the forefoot of the shoe. . Further specialized mechanical alterations can be achieved using a functional orthotic device which stabilizes rearfoot and midfoot function. Surgical intervention may be indicated in severe cases where abnormal pressure distribution is causing persistent and non resolvable ulceration
The relationship between diabetes and limited joint mobility has generated much research in recent times and yet much is still unknown about this phenomenon. The common theory is that the process of glycosylation causes stiffening of collagen in joint capsules leading to the restricted range of motion seen clinically. The foot joints most commonly affected by limited joint range of motion are the ankle joint and the first metatarsophalangeal joint. While some researchers indicate that a positive prayer sign is indicative of limited joint range of motion in the feet, this association is yet to be confirmed by large-scale, high-quality research. As such, the following discussion will not rely on the prayer sign but rather evaluate both the ankle and the first metatarsophalangeal joint range of motion as separate entities.This decision relies on the principle that there may be people who have a pre- existing ankle equinus or first ray pathomechanics which are independent to diabetes-induced limited joint range of motion. By relying on the prayer sign alone to determine limited joint range of motion, biomechanical abnormality in the forefoot, unrelated to the effects of glycosylation, may fail to be detected and corrected
Normal range of motion for the ankle joint is 100 of dorsiflexion. This range of motion is necessary to enable normal heel-to-toe function during gait. The primary treatment modality in patients with less than 100 of dorsiflexion is stretching of the posterior leg muscles. Stretching in the neuropathic patient must be carried out with caution and where possible the therapy should be conservative and carried out under supervision. The neuropathic patient is at greater risk of injury due to the lack of sensory feedback and may be at risk of tendon injury or joint disruption. Acupuncture or dry needling of the posterior leg muscles has been shown to relax the muscles prior to stretch and may prove of some benefit to patients with very tight posterior leg muscles. Surgical intervention in the form of a tendon-lengthening procedure is indicated in extreme cases where there is evidence of a shortened Achilles tendon and conservative therapy has failed. Surgical intervention may also be indicated in cases where a tight posterior muscle complex is believed to be the prima cause of plantar forefoot ulceration and where conservative therapy has failed.
Normal range of motion for the first metatarsophalangeal joint is greater than 500 of dorsiflexion during non weight bearing and greater than 120 of dorsiflexion during weight bearing. Adequate first metatarsophalangeal joint dorsiflexion is necessary to allow the heel to lift during the propulsive phase of gait. Inadequate first metatarsophalangeal joint dorsiflexion will cause joint destruction and potentially increase the risk of Charcot arthropathy. Clinical signs of limited joint range of motion in the first metatarsophalangeal joint include dorsal exostosis over the joint, hyperextended (dorsiflexed) hallux (first toe), and callus over the medial, plantar aspect of the hallux (first toe) as well as beneath the second to fifth metatarsophalangeal joints. Treatment for restricted range of motion in the first metatarsophalangeal joint is directed toward functional immobilization of the first metatarsophalangeal joint and joint manipulation to increase joint range of motion. Joint manipulation is a specialized area and will not be discussed here as this therapy should be carried out by skilled professionals. Immobilization of the first metatarsophalangeal joint can be achieved by using a rocker-sole under the forefoot of the shoe. . Further specialized mechanical alterations can be achieved using a functional orthotic device which stabilizes rearfoot and midfoot function. Surgical intervention may be indicated in severe cases where abnormal pressure distribution is causing persistent and non resolvable ulceration
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