Peripheral Neuropathy Diagnosis and Management

Vascular Assessment and Diagnosis

The American College of Cardiology recommends palpating femoral, popliteal, dorsalis pedis, and posterior tibial pulses, rated as 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding), to assess lower extremity vascular examination 1
The presence of all 4 posterior tibial and dorsalis pedis pulses is associated with a low likelihood of peripheral artery disease (PAD) 1
The American College of Cardiology suggests evaluating for abdominal and femoral bruits, elevation pallor/dependent rubor, asymmetric hair growth, and calf muscle atrophy to assess vascular health 1
Obtaining an ankle-brachial index (ABI) is recommended as many PAD patients are asymptomatic; ABI ≤0.90 confirms PAD 7, 3, 9, 5
Measuring toe-brachial index (TBI) is suggested if ABI >1.4 (noncompressible vessels in diabetes or chronic kidney disease); TBI ≤0.70 indicates PAD 3

The International Working Group on the Diabetic Foot (IWGDF) recommends categorizing patients by examination frequency using the IWGDF Risk Classification System 2, 6
Category 0 (no peripheral neuropathy): Annual screening 2
Category 1 (peripheral neuropathy alone): Every 6 months 2
Category 2 (peripheral neuropathy with PAD and/or foot deformity): Every 3-6 months 2
Category 3 (peripheral neuropathy with history of foot ulcer or amputation): Every 1-3 months 7
Instructing all at-risk patients on daily foot inspection, washing feet daily, never walking barefoot, wearing seamless socks, and inspecting inside shoes before wearing is crucial for preventive foot care 6, 10, 4

Optimizing glucose control in diabetic neuropathy to prevent progression, targeting individualized HbA1c goals, is recommended by the American Diabetes Association 4, 8
Addressing hypertension and hyperlipidemia aggressively as cardiovascular risk factors contribute to diabetic peripheral neuropathy progression is suggested by the American Heart Association 4
Correcting vitamin B12 deficiency when identified is recommended by the National Institutes of Health [[not available]]
Duloxetine 60 mg once daily is the first-line treatment for neuropathic pain, with the option to increase to 120 mg daily if needed, according to the American Academy of Neurology 4, 8

Numbness, loss of vibration sense (128-Hz tuning fork), impaired proprioception in "glove and stocking" distribution is a characteristic of large fiber neuropathy 8
Reduced or absent deep tendon reflexes, particularly Achilles tendon reflexes, is a sign of large fiber neuropathy 6, 8
Burning feet/hands, lancinating pain, dysesthesia, allodynia, and hyperalgesia with potentially normal standard neurophysiology is characteristic of small fiber neuropathy 8
Skin biopsy is the gold standard for diagnosing small fiber neuropathy, demonstrating degeneration of small C and Aδ fibers 8