CVR Physiotherapy › Chapter 6 › 6(h) and 6(i) Diabetes
Diabetes, diabetic foot, wound healing and diabetes insipidus
Diabetes is part of many long cases (CABG, MI, PAD, amputation, varicose veins) and was asked on its own as 7-mark questions on glycaemic control and diabetic foot care. Newer papers ask about wound healing and pressure sores. Learn the exercise prescription, the precautions, foot care with its reasons, and wound care.
- Syllabus
- Ch 6(i) Metabolic syndrome: diabetes mellitus and insipidus; 6(h) diabetic ulcers
- Priority
- Tier 2. 7-mark questions on diabetes (S16, W18, S19) and on wounds (W19 pressure sore; S24 and S25 wound healing); a co-existing condition in 10 long cases.
- Asked as
- 7m S16W18S19W19S24S25 3m S16S19S22
- Usual split
- 7-mark answers; part of long answers on CABG, PAD, amputation and venous disease
- Checked against
- ADA Standards of Care (2026); ADA position statement on physical activity and diabetes (2016); IWGDF diabetic foot guidelines (2023); 2022 renaming of diabetes insipidus. Full list under Sources.
- Content checked
- 19 October 2026. Next review due January 2027 (after ADA 2027).
- My revision
-
1Definition
Diabetes mellitus is a group of metabolic disorders with a raised blood glucose, caused by lack of insulin, poor response to insulin, or both.
Diabetic foot is infection, ulceration or destruction of tissues of the foot in a person with diabetes, usually because of nerve damage (neuropathy) and/or peripheral arterial disease.
Diabetes insipidus (now called arginine vasopressin (AVP) deficiency or AVP resistance) is a different disease: the body cannot concentrate urine, so the person passes large volumes of dilute urine and is always thirsty. Blood sugar is normal.
2Classification and grading
Types of diabetes mellitus
- Type 1: autoimmune destruction of insulin-producing cells; usually young; needs insulin; risk of ketoacidosis.
- Type 2: insulin resistance with failing insulin secretion; linked to obesity, inactivity and family history; the commonest type, and common in younger Indians.
- Gestational diabetes in pregnancy; other specific types (pancreatic disease, steroids).
Diagnosis (ADA)
| Test | Diabetes | Prediabetes |
|---|---|---|
| Fasting plasma glucose | 126 mg/dL or more | 100–125 mg/dL |
| 2-hour glucose after 75 g glucose drink | 200 mg/dL or more | 140–199 mg/dL |
| HbA1c | 6.5% or more | 5.7–6.4% |
| Random glucose with symptoms | 200 mg/dL or more | – |
Diabetic foot ulcer: Wagner grades
| Grade | Description |
|---|---|
| 0 | At-risk foot, no open wound (callus, deformity) |
| 1 | Superficial ulcer |
| 2 | Deep ulcer reaching tendon, capsule or bone, no abscess |
| 3 | Deep ulcer with abscess or osteomyelitis |
| 4 | Gangrene of part of the foot (toes or forefoot) |
| 5 | Gangrene of the whole foot |
Foot risk categories (IWGDF)
- 0, very low: no loss of protective sensation and no PAD. Screen yearly.
- 1, low: loss of protective sensation or PAD. Screen every 6–12 months.
- 2, moderate: two of: loss of sensation, PAD, foot deformity. Screen every 3–6 months.
- 3, high: loss of sensation or PAD plus a past ulcer, past amputation or end-stage kidney disease. Screen every 1–3 months.
3Causes and risk factors
- Type 2: obesity, especially abdominal; physical inactivity; family history; South Asian ethnicity (diabetes at lower BMI and younger age); unhealthy diet; age; gestational diabetes in the past.
- Diabetic foot: long duration, poor sugar control, neuropathy, PAD, foot deformity, smoking, kidney disease, walking barefoot, poor footwear, previous ulcer.
4Pathophysiology to impairments
Why the diabetic foot ulcerates: three causes
- Sensory neuropathy: loss of protective feeling, so injuries, tight shoes and burns are not noticed.
- Motor neuropathy: weak small foot muscles cause claw toes and prominent metatarsal heads, so pressure under the forefoot rises and callus forms.
- Autonomic neuropathy: no sweating, so dry, cracked skin lets bacteria in.
- Ischaemia (PAD) slows healing; high sugar weakens immunity, so infection spreads fast.
Repeated pressure under a callus causes bleeding and breakdown beneath it: a neuropathic ulcer. Add infection and ischaemia, and the result can be gangrene and amputation.
Other complications that affect physiotherapy
- Heart and vessels: heart attack (often silent), stroke, PAD.
- Eyes: retinopathy (bleeding risk with straining and head-down positions).
- Kidneys: nephropathy.
- Autonomic neuropathy: postural hypotension, fixed heart rate, poor heat tolerance.
- Musculoskeletal: frozen shoulder, stiff hands, Charcot foot (collapse of foot joints).
Stages of wound healing (3 marks in S19)
Haemostasis (minutes to hours) → inflammation (about days 1–5) → proliferation (about day 4 to week 3) → remodelling (week 3 to 1–2 years). See the full table on the burns page. Diabetes slows every stage, especially inflammation and proliferation.
Factors affecting wound healing (7 marks in S25)
- Local: infection; poor blood supply (arterial disease, pressure, tight dressings); oedema; dead tissue or foreign bodies; repeated shear, friction or pressure; a wound that is too dry or too wet; a large or deep wound; previous radiotherapy.
- General: older age; poor nutrition (protein, vitamin C, zinc); diabetes with high sugar; smoking; anaemia and low oxygen; obesity; drugs (steroids, chemotherapy); kidney or liver failure; reduced immunity; stress and poor sleep.
In a diabetic foot the main ones are high sugar, ischaemia, unnoticed pressure from neuropathy, infection and smoking. Answer S25 with this list plus the modalities in section 12.
5Clinical features
- Diabetes: thirst, frequent urination, tiredness, weight loss, blurred vision, slow-healing wounds, repeated infections; many type 2 patients have no symptoms.
- Neuropathic foot: numbness, tingling or burning, warm dry skin, callus, claw toes, good pulses (unless PAD), painless ulcer under the forefoot or heel.
- Ischaemic foot: cold, pale, absent pulses, painful ulcers at toes and heel.
- Diabetes insipidus: passing large amounts of pale urine (more than about 3 litres a day in adults), waking at night to pass urine, strong thirst, dehydration if water is not available.
Sweating, shaking, hunger, fast heart rate, confusion, slurred speech, unusual behaviour, seizures. Can happen during or many hours after exercise, especially with insulin or sulfonylureas.
6Investigations and foot tests
| Test | What it shows | Physio meaning |
|---|---|---|
| HbA1c | Average sugar over about 3 months | Poor control means slow healing, more care with exercise |
| Glucometer reading | Sugar now | Check before and after exercise if on insulin or sulfonylureas |
| 10 g monofilament | Loss of protective sensation | Foot risk category; protective footwear |
| 128 Hz tuning fork, ankle reflexes | Large-fibre neuropathy | Balance and fall risk |
| Pulses, ABI, toe pressures | PAD (ABI may be falsely high from calcified arteries) | Ischaemic foot needs vascular review |
| Lipids, kidney function, ECG, eye check | Complications | Modify exercise for heart, eye and kidney disease |
| Water deprivation test, sodium | Diabetes insipidus | Allow free access to water during sessions |
7Medical management
- Lifestyle: diet, physical activity, weight loss, stopping smoking.
- Medicines: metformin; sulfonylureas (cause hypoglycaemia); DPP-4 inhibitors; SGLT2 inhibitors and GLP-1 receptor agonists (also protect the heart and kidneys); insulin.
- Usual target HbA1c around 7% for many adults, set individually.
- Control BP and lipids; yearly eye, kidney and foot checks.
- Diabetic foot ulcer: off-loading (for example total contact cast), debridement, infection control, revascularisation if ischaemic, good sugar control.
- Diabetes insipidus: treat the cause; desmopressin for AVP deficiency.
8Complications and prevention
| Complication | What to look for | Physio role |
|---|---|---|
| Hypoglycaemia | Sweating, shaking, confusion during or after exercise | Check sugar; keep glucose tablets ready; rule of 15 |
| Foot ulcer, infection, amputation | Callus, blisters, redness, warmth, smell | Foot checks every session, footwear advice, off-loading |
| Silent heart attack | Breathlessness or fatigue without chest pain | Monitor HR and BP; use RPE |
| Retinal bleeding | Sudden blurred vision | Avoid heavy straining, breath-holding, jumping and head-down positions in advanced retinopathy |
| Falls | Numb feet, poor balance, postural hypotension | Balance training, safe footwear, slow position changes |
| Frozen shoulder, stiff hands | Painful restricted shoulder | ROM exercises, mobilisation |
9PT assessment
- Type and duration of diabetes, medicines (insulin, sulfonylureas), recent HbA1c and readings, hypoglycaemia episodes, complications.
- Activity level, occupation, diet habits, smoking, weight, BMI and waist.
- Feet: skin, nails, callus, deformity, footwear, monofilament sensation, vibration, pulses, ulcer description (site, size, depth, Wagner grade).
- BP lying and standing; resting HR; fitness (6MWT); strength; balance (single-leg stance, Timed Up and Go).
- Outcome measures: HbA1c, weight and waist, 6MWT, ulcer area, balance tests, quality of life.
10PT diagnosis by ICF
Diabetes appears inside other long cases. This practice case is built from those (not a single past paper).
Practice case: a 55-year-old shopkeeper with type 2 diabetes for 12 years, HbA1c 9%, numb feet, callus under the first metatarsal head, sedentary, overweight. He walks barefoot at home and in the shop.
| ICF component | From this case | Clinical reasoning |
|---|---|---|
| Health condition | Poorly controlled type 2 diabetes with peripheral neuropathy; high-risk foot | Long duration and high HbA1c |
| Body function impairments | Loss of protective sensation; callus and raised forefoot pressure; reduced fitness; excess weight; reduced balance | Neuropathy plus inactivity |
| Activity limitations | Safe walking on uneven ground; long standing in the shop | Numb feet and callus pain |
| Participation restrictions | At risk of losing work days to ulcers; limited social walking | Ulcer or amputation would stop work |
| Environmental factors | Barriers: barefoot habit, sweets and fried snacks at the shop. Facilitators: family, local clinic. | Education targets habits |
| Personal factors | 55-year-old man, low awareness of foot risk | Teach "why", not just "what" |
11Problem list and goals
- Short-term (4 weeks): daily foot inspection habit; protective footwear always; walking 20 minutes on most days with safe sugar readings; knows hypoglycaemia signs and treatment.
- Long-term (3–6 months): 150 minutes a week of aerobic activity plus resistance training twice a week; HbA1c and weight reduced; no ulcers; better balance.
12PT management
Exercise for glycaemic control (7 marks in S16 and W18)
Why exercise works: contracting muscle takes up glucose even without insulin; after training, insulin sensitivity improves for a day or more; exercise also reduces weight, BP, lipids and heart risk.
| Type | Dose |
|---|---|
| Aerobic | At least 150 min a week of moderate-to-vigorous activity, spread over 3–7 days, no more than 2 days in a row without exercise |
| Resistance | 2–3 sessions a week on non-consecutive days; 1–3 sets of 10–15 repetitions to near fatigue at first |
| Flexibility and balance | 2–3 days a week; stretches held 10–30 s, 2–4 repetitions; balance work for older adults and those with neuropathy |
| Less sitting | A few minutes of light activity every 30 minutes of sitting |
15 g, then 15 minutes
If sugar is below 70 mg/dL or symptoms appear: give 15 g of fast sugar (glucose tablets, 3 teaspoons of sugar in water, half a glass of juice), recheck after 15 minutes, repeat if still low, then a snack.
Diabetic foot care (7 marks in S19: "what is diabetic foot, how to take care of it, and why")
| Care | How | Why |
|---|---|---|
| Inspect daily | Look at soles and between toes with a mirror or a family member | Numb feet do not feel injuries |
| Wash and dry | Lukewarm water (test with the elbow), dry between toes | Prevents burns and fungal infection |
| Moisturise | Cream on dry skin, not between the toes | Dry skin cracks and lets bacteria in |
| Nail care | Cut straight across; no home surgery on corns | Prevents ingrown nails and wounds |
| Footwear | Soft, roomy, closed shoes with socks; check inside before wearing; never barefoot (home, temple, beach) | Protects against unnoticed injury and pressure |
| Avoid heat | No hot-water bottles, heating pads or walking on hot surfaces | Burns are not felt |
| Control sugar, stop smoking | Medicines, diet, exercise | Better healing and circulation |
| Seek help early | Any blister, cut, redness or swelling | Small wounds become ulcers in days |
- With an active plantar ulcer: off-load the foot (cast, boot, crutches); switch to non-weight-bearing exercise such as cycling with the other leg, arm ergometry or swimming once the wound allows.
- Neuropathy without ulcer: moderate weight-bearing walking is safe with proper footwear and daily checks.
Electrotherapy for wound healing (3 marks in S16 and S22; 7 marks in S24 and S25)
| Modality | Typical parameters | Effect |
|---|---|---|
| High-voltage pulsed current (electrical stimulation) | Twin-peak monophasic pulses, about 100 pulses per second, sensory-level voltage (often 100–150 V), 45–60 minutes, daily or 5 days a week; negative pole on an infected wound, positive to promote healing | Attracts repair cells, improves blood flow, antibacterial effect |
| Therapeutic ultrasound | Pulsed 20%, about 0.5 W/cm², 3 MHz, 5–10 minutes on the skin around the wound (not into an open wound without a sterile coupling) | Stimulates inflammation to move on, collagen formation |
| Ultraviolet (UVC) | Short-wave UV (about 254 nm), short exposures by test dose, protecting surrounding skin and eyes | Kills bacteria in infected wounds |
| Low-level laser | Low dose, about 1–4 J/cm² to wound edges | Cell stimulation, healing |
Exact parameters differ between electrotherapy books and trials. Write a range with the effect, and never use heat or electrotherapy over an ischaemic or numb area without checking circulation.
Pressure sores (pressure injuries) (7 marks in W19)
Damage to skin and the tissue under it from pressure, or pressure with shear, usually over a bony point: sacrum, heels, hips (greater trochanter), ischial tuberosities, back of the head, elbows. Patients at risk: bed- or chair-bound, numb skin (diabetes, spinal cord injury), ICU patients, poor nutrition, incontinence, older age.
| Stage | What you see |
|---|---|
| Stage 1 | Intact skin with redness that does not fade (blanch) when pressed |
| Stage 2 | Partial-thickness skin loss: shallow pink wound or blister; fat not visible |
| Stage 3 | Full-thickness skin loss: fat visible; no bone, tendon or muscle seen |
| Stage 4 | Full-thickness skin and tissue loss: muscle, tendon, ligament, cartilage or bone exposed or felt |
| Unstageable | Base covered by slough or eschar, so depth cannot be seen |
| Deep tissue pressure injury | Intact or broken skin with a persistent deep red, maroon or purple area |
Risk assessment: Braden scale (sensory perception, moisture, activity, mobility, nutrition, friction and shear; total 6–23). A score of 18 or less means the patient is at risk; the lower the score, the higher the risk.
Physiotherapy
- Relieve pressure: reposition on a schedule set for that patient; 30° tilted side-lying rather than lying straight on the hip; head of bed no higher than 30° unless breathing needs more; heels floated off the bed with a pillow under the calves.
- Surfaces: high-specification foam or alternating-pressure air mattress; pressure-relieving cushion in the chair; teach chair users to shift weight (push-ups or leaning) regularly.
- Move: bed mobility, sitting out and walking as early as possible; active and passive exercise to keep circulation and joint range.
- Avoid shear: lift, do not drag; use slide sheets.
- Help the wound heal: electrical stimulation has the best evidence of the physical modalities for stage 2 sores that are slow to heal and for stage 3–4 sores (parameters as in the table above); wound cleaning and dressing by the team; nutrition and continence care.
- Teach: daily skin checks, weight shifts, never sit or lie on a red area.
Classic answer vs current guideline: turning
Classic
Turn every patient every 2 hours.
Current (international guideline, 2019)
Set the turning frequency for each patient from their risk, skin checks, comfort and the mattress they are on.
Write in the exam
"Reposition at least every 2 hours, or as the patient's skin and support surface require."
Diabetes insipidus
- Allow free access to water and toilets during sessions; watch for dehydration (dizziness, dry mouth, fast pulse).
- Night-time urination raises the fall risk in older patients: night light, clear path.
- Seen in ICU after head injury or pituitary surgery: monitor fluid balance before mobilising.
13Precautions
- Check sugar before and after exercise if on insulin or sulfonylureas; carry fast sugar; avoid exercising at the peak action of insulin.
- Treat a low sugar first and do not start until it is back to normal.
- Avoid exercise when sugar is very high with ketones (mainly type 1).
- Advanced retinopathy: avoid vigorous exercise, heavy lifting, jumping, head-down positions and breath-holding.
- Neuropathy: proper footwear; check feet after each session; balance training.
- Autonomic neuropathy: change position slowly; use RPE instead of heart rate; avoid hot, humid days; drink water.
- Heart disease is often silent: report unusual breathlessness or fatigue.
- No heat or ice on numb skin; check circulation before any electrotherapy.
14Education and lifestyle
- Be active every day; break up sitting every 30 minutes.
- Eat regular meals with fewer refined carbohydrates and sweets; more vegetables, pulses and fibre.
- Reach a healthy weight and waist (Indian targets: BMI below 23; waist below 90 cm in men, 80 cm in women).
- Take medicines regularly; know your hypoglycaemia plan.
- Daily foot care for life; yearly eye, kidney and foot checks.
- Stop smoking and tobacco.
15Prognosis
Good control of sugar, BP and lipids, regular exercise and daily foot care greatly reduce complications. Most diabetic amputations start with a foot ulcer that could have been prevented.
16Exam corner
Past questions (MUHS, 2016–2026)
- 7-mark questionsPhysiotherapy for glycaemic control in diabetes (S16). Role of physiotherapy in diabetes (W18). What is diabetic foot, how to care for it, and why (S19). Physiotherapy for pressure sores (W19). Modalities for wound healing (S24). Factors affecting wound healing, with the modalities used (S25).
- 3-mark questionsThree electrotherapy modalities for an infected wound (S16). Stages of wound healing (S19). Three electrotherapy modalities with parameters for wound healing (S22).
- Inside long casesDiabetes with CABG (W18, S21), PAD (W22), amputation (S18, S19), varicose veins (S17), angina with EF 25% (S20), amputation (W19, S23, S25), MI (S26).
Technique cards for this topic: exercise physiology, exercise testing, electrotherapy and exercise.
Keywords to underline
insulin sensitivity 150 min a week no more than 2 days without exercise resistance 2–3 times a week hypoglycaemia rule of 15 loss of protective sensation monofilament off-loading daily foot inspection
Viva questions
- How does exercise lower blood sugar?
- What would you do if a patient becomes sweaty and confused during exercise?
- Why do neuropathic ulcers form under the metatarsal heads?
- Which exercises should a patient with proliferative retinopathy avoid?
- How is diabetes insipidus different from diabetes mellitus?
Test yourself
Answer on paper first, then open the answer.
7 mPhysiotherapy management for glycaemic control in diabetes mellitus.
Why exercise works; assessment and screening; aerobic and resistance prescription (ADA doses); flexibility and balance; breaking up sitting; precautions (hypoglycaemia, retinopathy, neuropathy, autonomic); foot care; education; monitoring outcomes (HbA1c, weight).
3 mThree electrotherapeutic modalities with parameters for wound healing.
- High-voltage pulsed current: about 100 pps, sensory level, 45–60 min, negative pole for infected wound.
- Pulsed ultrasound: 20%, about 0.5 W/cm², 3 MHz, 5–10 min around the wound.
- UVC about 254 nm, short test-dosed exposure for bacterial kill. (Laser 1–4 J/cm² also accepted.)
MCQA patient on insulin feels shaky and sweaty mid-session; glucometer shows 60 mg/dL. Best action:A. Continue at lower intensityB. Stop, give 15 g fast sugar, recheck in 15 minutesC. Give insulinD. Tell him to rest at home
B. The rule of 15 treats mild hypoglycaemia safely.
MCQWhich footwear advice is correct for a diabetic with numb feet?A. Walk barefoot at home to strengthen the feetB. Tight shoes for supportC. Soft, roomy closed shoes with socks, checked inside before wearingD. Hot-water soaks every night
C. Numb feet cannot sense injury; protection and daily checks prevent ulcers.
Sources
Notes written in original words. Numbers were checked against the sources below.
- MUHS BPTh syllabus (2012) and MUHS IV BPTh question papers 2016–2026 (muhsonline.com, unofficial archive; Dhole Patil College of Physiotherapy past-paper page).
- American Diabetes Association. Standards of Care in Diabetes 2026. Diabetes Care 2026.
- Colberg SR, et al. Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016;39:2065–79. Key points summary: PMC.
- International Working Group on the Diabetic Foot (IWGDF) Guidelines 2023.
- Arima H, et al. Changing the name of diabetes insipidus: a position statement. 2022.
- Electrical stimulation parameters: reviews of high-voltage pulsed current in chronic wounds (PMC); electrotherapy.org.
- RSSDI clinical practice recommendations for type 2 diabetes (India), 2022.
- National Pressure Injury Advisory Panel. Pressure injury stages (2016). npiap.com
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline, 3rd edition (2019).
Educational notes for exam preparation. Not medical advice. Hospital protocols and the treating doctor's instructions come first.
Version 1. Content checked 19 October 2026. Next review January 2027.