Comparison of Toe Flexor Muscle Strength Between the Elderly with and Without Type 2 Diabetes Mellitus


  • Warunporn Sarakit นักศึกษา หลักสูตรวิทยาศาสตรมหาบัณฑิต สาขากายภาพบำบัด คณะสหเวชศาสตร์ มหาวิทยาลัยนเรศวร
  • Saowanee Luangaram Department of Physical therapy, Faculty of Allied Health Sciences, Naresuan University
  • Chaiyong Jorrakate Department of Physical therapy, Faculty of Allied Health Sciences, Naresuan University


Toe Flexor strength, Diabetes mellitus, Elderly


This research aims to compare toe flexor strength (TFS) between the elderly with (N = 20) and without (N = 20) type 2 diabetes mellitus and to explore the relationship between TFS and walking efficiency in both elderly groups. Toe grip dynamometer was used to test the TFS. Walking efficiency was determined with timed up and go (TUG) test. The results found that toe flexor muscle strength in elderly volunteers with and without type 2 diabetes mellitus showed no differences except TFS of left toes per body weight, with no relationship between TFS and walking efficiency, although volunteers with type 2 diabetes mellitus took longer to perform the TUG test than those without type 2 diabetes mellitus.


Wong E, Backholer K, Gearon E, Harding J, Freak-Poli R, Stevenson C, et al. Diabetes and risk of physical disability in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2013; 1(2): 106-114.

Wrobel JS, Najafi B. Diabetic foot biomechanics and gait dysfunction. J Diabetes Sci Technol. 2010; 4(4): 833-845.

Andreassen CS, Jakobsen J, Andersen H. Muscle weakness: a progressive late complication in diabetic distal symmetric polyneuropathy. Diabetes. 2006; 55(3): 806-812.

Andersen H, Nielsen S, Mogensen CE, Jakobsen J. Muscle strength in type 2 diabetes. Diabetes. 2004; 53(6): 1543-1548.

Bus SA, Yang QX, Wang JH, Smith MB, Wunderlich R, Cavanagh PR. Intrinsic muscle atrophy and toe deformity in the diabetic neuropathic foot: a magnetic resonance imaging study. Diabetes Care. 2002; 25(8): 1444-1450.

Vichayanrat A, Puavilai G, Nitiyanant W, Vannasaeng S. Textbook of diabetes mellitus. 1st ed. Bangkok: Ruenkaew Printing; 2003.

Soysa A, Hiller C, Refshauge K, Burns J. Importance and challenges of measuring intrinsic foot muscle strength. J Foot Ankle Res. 2012; 5(1): 29.

Lambrinudi C. Use and Abuse of Toes. Postgrad Med J. 1932; 8(86): 459–464.

Goldmann JP, Bruggemann GP. The potential of human toe flexor muscles to produce force. J Anat. 2012; 221(2): 187-194.

Guccione AA, Wong RA, Avers D. Geriatric physical therapy. 3rd ed. St. Louis: Elsevier/Mosby; 2012.

Suwa M, Imoto T, Kida A, Yokochi T. Early reduction in toe flexor strength is associated with physical activity in elderly men. J Phys Ther Sci. 2016; 28(5): 1472-1477.

Kanjanawasee T. Research Methodology. 2nd ed. Bangkok: Pintanjai Part., Ltd.; 2018. Thai.

Abe T, Thiebaud RS, Loenneke JP, Mitsukawa N. Association between toe grasping strength and accelerometer-determined physical activity in middle-aged and older women. J Phys Ther Sci. 2015; 27(6): 1893-1897.

Thaweewannakij T, Amatachaya S, Peungsuwan P, Mato L. Balance, fall and quality of life in active and inactive elderly. J Med Tech Phy Ther. 2010; 22(3): 271-279. Thai.

American College of Sports Medicine. ACSM's guidelines for exercise testing and prescription 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2000.

Nualnetr N, Sriruang J, Boonmat R, Chaiyamoon S, Boonyarat S. Assessment of risk of falling in community-dwelling elderly by using the Thai Fall Risk Assessment Tool and the Berg Balance Scale. J Med Tech Phy Ther. 2010; 22(2): 179-187.

Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care. 2010; 33(12): 2692-1696.

Diabetes Association of Thailand. Clinical practice guideline for diabetes 2014. 1st ed. Bangkok: Aroonkarnpim Ltd.; 2014.

Uritani D, Fukumoto T, Matsumoto D, Shima M. Associations between toe grip strength and hallux valgus, toe curl ability, and foot arch height in Japanese adults aged 20 to 79 years: a cross-sectional study. J Foot Ankle Res. 2015; 8: 18.

Jalayondeja C. Falls screening by Timed Up and Go (TUG). J Med Tech Phy Ther. 2014; 26(1): 5-16. Thai.

Uritani D, Fukumoto T, Matsumoto D, Shima M. Reference values for toe grip strength among Japanese adults aged 20 to 79 years: a cross-sectional study. J Foot Ankle Res. 2014; 7: 28.

Lui J, MacGillivray MK, Sawatzky BJ. Test-retest reliability and minimal detectable change of the SmartWheel clinical protocol. Arch Phys Med Rehabil. 2012; 93(12): 2367-2372.

Cetinus E, Buyukbese MA, Uzel M, Ekerbicer H, Karaoguz A. Hand grip strength in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract. 2005; 70(3): 278-286.

Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010; 39(4): 412-423.

Park SW, Goodpaster BH, Strotmeyer ES, de Rekeneire N, Harris TB, Schwartz AV, et al. Decreased muscle strength and quality in older adults with type 2 diabetes: the health, aging, and body composition study. Diabetes. 2006; 55(6): 1813-1818.

Van Sloten TT, Savelberg HH, Duimel-Peeters IG, Meijer K, Henry RM, Stehouwer CD, et al. Peripheral neuropathy, decreased muscle strength and obesity are strongly associated with walking in persons with type 2 diabetes without manifest mobility limitations. Diabetes Res Clin Pract. 2011; 91(1): 32-39.

IJzerman T, Schaper N, Melai T, Meijer K, Willems P, Savelberg H. Lower extremity muscle strength is reduced in people with type 2 diabetes, with and without polyneuropathy, and is associated with impaired mobility and reduced quality of life. Diabetes Research and Clinical Practice. 2012; 95: 345-351.

Clarkson HM. Musculoskeletal assessment: Joint Range of Motion and Manual Muscle Strength. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000.

Kapandji IA. Physiology of the Joints: The Physiology of the Joints, Volume 2 Lower Limb v. 2. 6th ed. London, United Kingdom: Elsevier Health Sciences; 2011.

Amput P, Srithawong A, Sittitan M, Wongphon S, Sangkarit N. The assessment of balance ability in person with type 2 diabetes mellitus. Bull Chiang Mai Assoc Med Sci. 2016; 49(3): 338-343. Thai.

Bischoff HA, Stahelin HB, Monsch AU, Iversen MD, Weyh A, von Dechend M, et al. Identifying a cut-off point for normal mobility: a comparison of the timed 'up and go' test in community-dwelling and institutionalised elderly women. Age Ageing. 2003; 32(3): 315-320.

Jones K, Barker K. Human Movement Explained. Edinburgh: Butterworth-Heinemann; 1996.