For decades, the standard response to a diabetic foot ulcer has been to shut everything down. We focus so intently on offloading that we often inadvertently prescribe a total sedentary lifestyle. But as our colleagues at the University of Michigan point out in their recent review, we need to shift the narrative toward “Toe, Flow, and Go”—ensuring that while we protect the wound, we don’t sacrifice the patient’s systemic health.
The term “offloading” has become conflated with a reduction in movement altogether, which increases sedentary time and the associated risks of adverse health outcomes. It is time to establish a middle ground where we prescribe offloading without allowing it to come at the expense of movement.
Movement as Medicine
Evidence suggests that movement-based interventions—ranging from simple ankle flexions to supervised cycling—can yield significant physiological and psychosocial benefits for patients with active ulcers.
- The “Exerkine” Effect: Exercise triggers the release of bioactive molecules called exerkines. These molecules promote inter-organ crosstalk, potentially enhancing vascular health and glycemic control.
- Proof of Concept: Studies using Buerger-Allen exercises (BAE) have demonstrated improved peripheral skin circulation in the feet of patients with diabetes through simple postural changes and skeletal muscle pump activation.
- Targeted Benefits: Research shows that even single bouts of toe-flexion exercises can immediately increase skeletal muscle blood flow in the area surrounding an ulcer.
- Aerobic Impact: In supervised trials, patients using specialized offloading pedals for cycling experienced a 94% reduction in wound size over 12 weeks.
Integrating Physical Therapy: The Core of the Team
At the heart of the “Toe, Flow, and Go” model is the integration of Physical Therapy (PT) into the limb preservation team. A PT-guided approach is essential to navigate the delicate balance between protecting the wound and maintaining systemic health.
- Weight-Bearing Progression: PTs are uniquely qualified to design safe, gradual increases in activity. This prevents the sudden accumulations of tissue stress that lead to ulcer recurrence while keeping the patient mobile.
- Addressing Conflicting Messaging: Patients often face a “healthcare barrier” where podiatrists tell them to limit weight-bearing while other doctors urge exercise. Our multidisciplinary team, including PT, provides a unified and clear pathway for the patient.
- Psychosocial Support: Since DFUs are associated with high rates of depression and anxiety, the positive reinforcement and community found in supervised exercise programs can significantly improve treatment adherence and self-efficacy.
Moving the Needle
Limb preservation is not just about a “healed” wound; it is about a functional, active patient. By leveraging the movement continuum—from reducing sedentary time to structured exercise—we move past the era of total inactivity. We must protect the Toe, optimize the Flow, and empower the patient to Go.
Nakamura JE, Fong AJ, Lane AD, Munson ME, Schmidt BM, Holmes CM, Haus JM. Rethinking diabetic foot ulcer care: Integrating exercise and physical activity. Journal of Diabetes and Its Complications. December 2025. Ann Arbor, MI, USA.
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