Diabetic peripheral neuropathy is nerve damage from long-term high blood glucose, usually starting in the toes and spreading upward in a stocking-glove pattern. Loss of protective sensation makes it a leading cause of foot ulcers and amputations.
Key symptoms
- Numbness, tingling or burning in the feet
- Pain worse at night
- Feeling of walking on cotton; poor balance
- Painless injuries or ulcers on the feet
What you find on exam
- Monofilament test for protective sensation
- Vibration sense with a 128 Hz tuning fork, and ankle reflexes
- Foot inspection: skin, calluses, deformities, ulcers
- Pedal pulses to check circulation
Tests
- HbA1c and glucose
- Vitamin B12 (especially on metformin), thyroid tests, kidney function
- Serum protein electrophoresis if atypical
- Nerve conduction studies only for atypical features
Treatment basics
- Better control of glucose, blood pressure and lipids
- Painful neuropathy: duloxetine, pregabalin or gabapentin
- Daily foot checks, proper shoes and podiatry care
- Foot exam every year, more often if sensation is lost
Red flags
- Foot ulcer, infection or black skin
- Hot, swollen, red foot (Charcot foot)
- Rapidly progressing or asymmetric weakness
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.