Diabetes is a chronic-degenerative metabolic disorder that has reached pandemic proportions,
mainly because of the increasing incidence and prevalence of type 2 diabetes mellitus (T2D).
According to the International Diabetes Federation (IDF, 2017), 425 million people suffer
from diabetes worldwide and these may rise to 629 million in 2045 . Within this
epidemiological perspective, diabetes emerges as one of the main metabolic disorders with
substantial costs for regional and national sanitary systems.
Diabetes hurts cardiovascular function due to chronic hyperinsulinemia and hyperglycemia,
along with increased advanced glycation end products (AGEs), pro-inflammatory cytokines,
oxidative stress, obesity, dyslipidemia, and physical inactivity, all of which contribute to
vascular dysfunction. In particular, several studies have shown that AGEs exert their
negative effects through binding to a specific cellular receptor (RAGE), found in several
cell systems such as monocytes and endothelial cells. However, little attention has been
paid, so far, to alterations in the musculoskeletal system, which may contribute to the
decline of the general state of health of diabetic people and may limit the therapeutic use
of exercise in these subjects.
Diabetes causes non-enzymatic glycation of soft tissues, including muscle and tendon, leading
to an increase in muscle and tendon stiffness. It was observed that Achilles tendon stiffness
and skin connective tissue cross-linking are greater in diabetic patients compared to
controls and it has been suggested that the elevated tendon stiffness may influence gait
parameters. Indeed, during walking, diabetic patients display less Achilles tendon
elongation, higher tendon stiffness and higher tendon hysteresis compared to healthy
controls. The higher energy cost of walking in diabetic patients could thus be related to an
impairment of the Achilles tendon function. The stiffening of the muscle, on the other hand,
reduces its capability to change in shape, affecting its potential for modulating the
mechanical request during contraction (and locomotion), also increasing the metabolic
demands. Therefore, investigating the mechanical alterations caused by an increase in muscle
and tendon stiffness could provide new insights into diabetes pathophysiology.
Training strategies able to reduce muscle and tendon stiffness are expected to improve
muscle-tendon function and locomotor capability of diabetic patients. Even if strength and
endurance training protocols allow to improve both blood glucose and muscle contractile
function, they seem ineffective in reducing muscle and tendon stiffness in T2D patients.
Notably, these training modalities present a significant dropout in the diabetic population,
generally higher than 25%.
Static and dynamic stretching are effective in decreasing muscle and tendon stiffness but, in
both cases, the decrease in stiffness is associated with a temporary decrease in muscle and
tendon mechanical function.
Recently, a new stretching modality (minute oscillation stretching, MOS) was proposed that
allows to condition the plantar-flexors muscle-tendon units by providing repetitive small
longitudinal length changes using a passive stretch of the ankle joint. In young and healthy
participants, a single session of unilateral MOS was sufficient to reduce muscle and tendon
stiffness without affecting the muscle strength of the tested leg. Since the plantar-flexor
muscles are the most important propulsive muscles for human locomotion, it can be expected
that MOS training for the plantar-flexor may improve locomotor capability in diabetic people
too. It is noteworthy that, due to the current SARS-Covid-19 pandemic, this training modality
can be easily performed at home, under telemedicine training supervision, since no specific
equipment is needed.
To summarize, a better understanding of the altered muscle and tendon mechanical properties
in TD2 patients and of the effects that these alterations have on muscle contraction and
locomotion capability can help in furthering our understanding on how diabetes affects
physical activity, leading to inactivity. Finally, to investigate if and how these
alterations could be reduced using a simple training program (MOS training), can help in
designing more effective interventions, allowing to prescribe training modalities that these
patients can easily perform (possibly limiting dropout).
