Bilateral Neuropathic Foot Pain in Diabetic Patients

Epidemiology and Clinical Significance

Painful diabetic peripheral neuropathy (DPN) affects 10-26% of diabetic patients, with a prevalence of 16% in one population-based study, and 12.5% of patients with painful DPN never report symptoms to their physician, while 39% never receive treatment for their pain 1

Pain is invariably bilateral and symmetrical, and asymmetrical symptoms should prompt investigation for alternative etiologies, with nocturnal exacerbation being characteristic, often causing severe sleep disturbance 2
Symptoms begin distally in the feet and may progress proximally up the limbs in a length-dependent fashion, with patients describing burning pain, "electrical shock" sensations, stabbing or knife-like pains, uncomfortable tingling, and allodynia 2

The diagnosis relies on patient description of distal, symmetrical pain with nocturnal exacerbation, and clinical examination should demonstrate abnormalities in at least one of: temperature sensation, pinprick sensation, vibration perception, pressure sensation, or ankle reflexes, with nerve conduction studies being particularly important to exclude entrapment syndromes and other focal causes 2

The presence of neuropathic pain significantly affects patient outcomes, with severe sleep disturbance leading to fatigue and reduced daily activities, and over two-thirds of patients with painful diabetic neuropathy having anxiety and/or depression 3