Assessment and Management of Diabetic Foot Neuropathy

Initial Clinical Assessment

The American Diabetes Association recommends performing a focused examination to confirm loss of protective sensation (LOPS) using at least two tests, including 10-g monofilament testing, 128-Hz tuning fork for vibration sense, pinprick sensation testing, and ankle reflex assessment 1
The International Working Group on the Diabetic Foot (IWGDF) suggests that one or more abnormal tests confirms LOPS, while two normal tests (with no abnormal findings) rules it out 1
It is critical to distinguish neuropathy from ischemia, as management differs substantially, and the American College of Cardiology recommends palpating all four pedal pulses and obtaining an ankle-brachial index (ABI) if pulses are diminished or absent 1, 2

The International Working Group on the Diabetic Foot (IWGDF) recommends using the IWGDF Risk Classification System to stratify patients into categories based on their risk of developing foot ulcers or amputations, with Category 1 being peripheral neuropathy alone, Category 2 being neuropathy with PAD and/or foot deformity, and Category 3 being neuropathy with history of ulcer or amputation 2
The American Diabetes Association suggests that patients with Category 1 should be examined every 6 months, Category 2 every 3-6 months, and Category 3 every 1-3 months 2

The American Diabetes Association recommends optimizing glucose control aggressively but carefully, with target individualized HbA1c goals based on patient factors, and avoiding dropping HbA1c >3% rapidly, as this can cause treatment-induced neuropathy with paradoxical worsening 4, 6
The American Heart Association suggests addressing cardiovascular risk factors, including optimizing blood pressure control and managing hyperlipidemia, to prevent neuropathy progression 2, 5, 6

The American Academy of Neurology recommends duloxetine 60 mg once daily as the preferred first-line agent for symptomatic pain management, with the option to increase to 120 mg daily if needed for additional benefit, and notes that it has the strongest evidence base for diabetic peripheral neuropathy 6
The American Pain Society suggests alternative first-line options, including pregabalin and gabapentin, if duloxetine is contraindicated or not tolerated 5, 6, 7

The American Diabetes Association recommends well-fitted walking shoes or athletic shoes that cushion feet and redistribute pressure, and callus debridement by a foot care specialist with scalpel, for patients with evidence of increased plantar pressure 1, 3
The International Working Group on the Diabetic Foot (IWGDF) suggests extra wide or deep shoes for bony deformities, such as hammertoes, prominent metatarsal heads, or bunions, and custom-molded shoes for extreme deformities 1, 3

The American Diabetes Association recommends instructing all at-risk patients on daily foot inspection, washing feet daily and drying thoroughly, never walking barefoot, wearing seamless socks, and inspecting inside shoes before wearing 1, 2
The American Podiatric Medical Association suggests substituting other sensory modalities, such as hand palpation or visual inspection, for surveillance since protective sensation is lost, and wearing loose-fitting shoes, roomy cotton socks, and padded slippers 1, 7