Common injuries associated with a diabetic state are shoulder adhesive capsulitis ("frozen shoulder"), carpal tunnel syndrome (wrist pain), metatarsal fractures (foot bones), and neuropathy-related joint disorders (e.g., Charcot foot) in people with peripheral neuropathy. People with long-standing diabetes are additionally prone to nerve compression syndromes at the elbow and wrist that may be aggravated by repetitive activities, prolonged gripping, or direct nerve compression during weight training, cycling, and other activities1. In most cases, effective glycemic management reduces the risk for developing these injuries, which are largely the result of glycation of joint structures that increases rigidity2,3. Engaging in flexibility exercises done with resistance work that emphasizes and maintains a full range of motion around all the joints can also be beneficial4.
Causes of Overuse Injuries
In most sports and activities, overuse injuries are the most common and challenging to diagnose and treat, and they often worsen over time if neglected. By definition, an overuse injury is caused by excessive use of a particular joint. Overuse injuries are more common in people with diabetes because of structural changes in their joints caused by long-term elevations in blood glucose levels and ensuing oxidative stress and damage2,3. Regardless of the contributing cause, all overuse injuries are treated the same way. Moreover, their onset usually can be linked to changes in athletic endeavors or techniques, such as rapid progression in physical activity participation. To prevent such injuries, individuals should make only gradual increases in training duration, frequency, or intensity to allow the body time to adapt to minor traumas imposed by exercise, which can occur with adequate time for recovery and recuperation.
Some people are prone to developing overuse injuries, but their development is more often related to anatomical, biomechanical, or other considerations5. For instance, imbalances between strength and flexibility around joints (e.g., quads vs. hamstring strength) can predispose a person to hamstring pulls or other injuries6. Uneven body alignment, such as knock-knees, bowed legs, unequal leg lengths, and flat or high-arched feet, also can contribute7. Even old injuries lead to a greater likelihood of overuse injuries, as do factors like the type of running shoes an individual wears, the terrain (hilly, flat, or uneven), and whether exercise is done on hard surfaces like concrete roads or floors or softer ones like grass, dirt, or gravel trails, asphalt, and cushioned floors.
Many overuse injuries involve inflammation of an area, or redness, soreness, and swelling, designated as "–itis" at the end of its name. Tendinitis is inflammation of tendons, which attach muscles to bones; it is a common overuse injury that results from a tendon rubbing repeatedly against a bony structure, ligament, or another tendon or from being impinged8. Tennis elbow is a type of tendinitis on the outside of the elbow common in tennis players as well as rowers, carpenters, gardeners, golfers, and other exercisers who repeatedly bend their arms forcefully1. Swimmers often develop tendinitis and other impingement syndromes in the rotator cuff (shoulder) because of the overhead movement required by the sport8. In sports that involve running and jumping, tendinitis often occurs in the knee, foot, and Achilles' (heel) tendons.
Prevention of Overuse Injuries
Individuals who are experiencing nagging aches and pains that are only minor should simply cut back on the intensity, frequency, and duration of irritating activities to bring relief of symptoms9. One way to prevent problems in the first place is to adopt a hard/easy workout schedule in which workouts are alternated and varied by the day to avoid overstressing joints in the same way with every workout10. If problems are related to anatomical concerns, individuals should consider getting orthotics (e.g., to correct leg-length discrepancies) or do other activities that do raise injury risk, such as working out on an elliptical trainer a few days a week instead of always running outdoors on asphalt. In addition, working with a coach or teacher or taking lessons can help improve training and technique. Engaging in proper warm-ups and cooldowns, icing inflamed joints after workouts, and using NSAIDs also can control inflammation and pain. Some key strategies associated with prevention of acute and chronic injuries are covered in Table 16.4.
Engaging in cross-training can help prevent and treat overuse injuries11. Individuals should do other activities to maintain their overall fitness levels while the injured area recovers. For example, with lower leg pain, an individual can still work the upper body by doing activities that allow the legs to rest and recuperate. They also can alternate weight-bearing activities like walking or running with non-weight-bearing ones, such as swimming, upper-body work, and stationary cycling10. Strengthening the muscles around the previously injured joint to prevent recurrence, especially following tendinitis, is critical to preventing its recurrence. For example, following a shoulder joint injury like rotator cuff tendinitis and impingement, resistance work should include all sections of the deltoid muscle (in particular), along with exercises for the biceps, triceps, pectoral muscles, upper-back muscles, and neck muscles.
Table 16.4. Prevention of Acute and Chronic Injuries Associated with Physical Activity
- Never bounce during stretches because doing so can cause injuries, although dynamic stretching is fine (movement stretches).
- If currently sedentary, start slowly and progress cautiously to avoid delayed-onset muscle soreness, an acute injury, or overtraining injuries.
- Warm up with stretches and easy aerobic work before undertaking vigorous exercise.
- Choose appropriate exercises, such as swimming if recovering from an ankle or knee injury.
- Vary the exercise program occasionally or try out new activities to emphasize different muscle groups and increase overall fitness.
- Cross-train to reduce the risk of injury by varying muscle and joint usage.
- Wear appropriate shoes and socks, and check feet after each exercise session.
- Avoid going back to normal activities until symptoms have almost completely gone away.
- For best results, include a warm-up and cool-down period with each exercise session.
In conclusion, individuals with diabetes are more prone to developing overuse injuries with a slower onset that can limit movement around joints, such as adhesive capsulitis. Anyone experiencing nagging aches and pains that are only minor should simply cut back on the intensity, frequency, and duration of irritating activities to bring relief of symptoms, along with engaging in hard and easy days and cross-training.
- Chumbley, E. M., F. G. O'Connor, and R. P. Nirschl: Evaluation of overuse elbow injuries. Am Fam Physician 61 (3):691–700, 2000
- Abate, M., C. Schiavone, P. Pelotti, and V. Salini: Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 23 (4):997–1003, 2011
- Basta, G., G. Lazzerini, M. Massaro, T. Simoncini, P. Tanganelli, C. Fu, T. Kislinger, D. M. Stern, A. M. Schmidt, and R. De Caterina: Advanced glycation end products activate endothelium through signal-transduction receptor RAGE: a mechanism for amplification of inflammatory responses. Circulation 105 (7):816–822, 2002
- Herriott, M. T., S. R. Colberg, H. K. Parson, T. Nunnold, and A. I. Vinik: Effects of 8 weeks of flexibility and resistance training in older adults with type 2 diabetes. Diabetes Care 27 (12):2988–2989, 2004
- Van Ginckel, A., Y. Thijs, N. G. Hesar, N. Mahieu, D. De Clercq, P. Roosen, and E. Witvrouw: Intrinsic gait-related risk factors for Achilles tendinopathy in novice runners: a prospective study. Gait Posture 29 (3):387–391, 2009
- Zifchock, R. A., I. Davis, J. Higginson, S. McCaw, and T. Royer: Side-to-side differences in overuse running injury susceptibility: a retrospective study. Hum Mov Sci 27 (6):888–902, 2008
- Collins, M., and S. M. Raleigh: Genetic risk factors for musculoskeletal soft tissue injuries. Med Sport Sci 54:136–149, 2009
- Rechardt, M., R. Shiri, J. Karppinen, A. Jula, M. Heliovaara, and E. Viikari-Juntura: Lifestyle and metabolic factors in relation to shoulder pain and rotator cuff tendinitis: a population-based study. BMC Musculoskelet Disord 11:165, 2010
- Fry, R. W., A. R. Morton, and D. Keast: Overtraining in athletes. An update. Sports Med 12 (1):32–65, 1991
- Fry, R. W., A. R. Morton, and D. Keast: Periodisation and the prevention of overtraining. Can J Sport Sci 17 (3):241–248, 1992
- Vleck, V. E., D. J. Bentley, G. P. Millet, and T. Cochrane: Triathlon event distance specialization: training and injury effects. J Strength Cond Res 24 (1):30–36, 2010
This article is excerpted from Chapter 16 of Exercise and Diabetes: A Clinician's Guide to Prescribing Physical Activity, a case-study based book available through the American Diabetes Association in June 2013 and written by Dr. Sheri Colberg (find more information about the book online at www.shericolberg.com/exercise-diabetes.asp).
In addition, anyone wishing to earn free CME credits through the ADA for completing a new self-assessment program on exercise and diabetes may do so now through the ADA's web site at http://professional.diabetes.org/ce.
Copyright © 2013 Diabetes In Control, Inc.