Synopsis
Detect diabetic nerve injury before ulceration or organ dysfunction, exclude treatable alternatives, relieve neuropathic pain safely, and protect function through multidisciplinary follow-up.
- Distal symmetrical sensorimotor polyneuropathy usually begins in the toes with length-dependent numbness, burning, electric pain or loss of protective sensation.
- A 10 g monofilament identifies loss of protective sensation but does not exclude small-fibre painful neuropathy when the result is normal.
- Check pulses, skin, footwear, deformity, callus and previous ulcer at every formal foot assessment because neuropathy converts pressure into unnoticed injury.
Key red flags
Rapid evolution, pronounced weakness, asymmetry, a sensory level, cranial signs or sphincter change requires urgent neurological reassessment rather than routine diabetes follow-up.
Investigation priorities
Define distribution, protective sensation, motor involvement and immediate ulcer risk.
Management branches
A person attends annual diabetes review or reports sensory symptoms, pain, balance change or unnoticed injury.
- Ask about pain, numbness, balance, falls, skin injury and footwear, then inspect both feet, palpate pulses and test protective sensation using the local NICE-aligned technique.
- Classify foot risk from neuropathy, vascular supply, deformity, callus, previous ulcer or amputation and renal replacement therapy, and arrange the required foot-protection follow-up.
Key medicines
DuloxetineFor licensed diabetic peripheral neuropathic pain, the starting and recommended maintenance dose is 60 mg once daily with or without food; review response after two months and follow the exact current product information.