Guideline sources The following summarized guidelines for the evaluation of distal symmetric polyneuropathy are prepared by our editorial team based on guidelines from the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM/AAN 2009). 1 2 2 2 3 Definition Distal symmetric polyneuropathy is diffuse length-dependent peripheral neuropathy characterized by numbness, tingling, pain, and/or weakness that typically starts in the toes and spreads proximally. 2 Epidemiology Distal symmetric polyneuropathy is most commonly caused due to diabetes (32-53%), idiopathic reasons (24-27%), alcohol, vitamin B 12 deficiency, chemotherapy, CKD, paraproteinemia, and inherited conditions (hammertoes, high arches, Charcot Marie Tooth). Other causes include pre- diabetes, infections, inflammation, toxins, autoimmunity, neoplasms, and paraneoplasms. 2 Disease course Clinical manifestations of distal symmetrical polyneuropathy include numbness, tingling, pain, starting in the toes with proximal spread, decreased pinprick and vibration sensation in a stocking-glove distribution, decreased reflexes starting at the ankles, weakness of toe extension, or trouble walking on heels. Progression may lead to weakness, the involvement of fingertips, balance issues resulting in falls and fractures, risk of ulcerations and amputations. 2 Prognosis and risk of recurrence Lower extremity amputations are associated with early postoperative mortality of up to 22%. 3 https://web.pathway.md/diseases/reclc5w1ab3TVTyjg 1/2 6/29/23, 10:20 PM Distal symmetric polyneuropathy Pathway Guidelines 1. Diagnostic investigations Laboratory assessment: Consider screening laboratory tests (e.g., blood glucose, serum B12 and SPEP) in all patients with polyneuropathy. C Consider testing for impaired glucose tolerance in patients with distal symmetric sensory polyneuropathy in whom there is no evidence of diabetes mellitus. C Genetic testing: obtain genetic testing for the accurate diagnosis and classification of hereditary neuropathies. A Show 2 more Clinical findings Symptoms Past medical history Muscle weakness Diabetes mellitus Numbness of soles of feet Poorly controlled diabetes Pain Lab findings Tingling Hyperglycemia Neurological exam Neuropathy References 1. England JD, Gronseth GS, Franklin G et al. Practice Parameter: evaluation of distal symmetric polyneuropathy: role of laboratory and genetic testing (an evidence-based review). Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Neurology. 2009 Jan 13;72 2 185 92. Open 2. Brian C. Callaghan, Raymond S. Price, and Eva L. Feldman. Diagnostic and Therapeutic Advances: Distal Symmetric Polyneuropathy. JAMA. 2015 Nov 24; 314 20 2172 2181. Open 3. Ayeshmanthe Rathnayake, Apoorva Saboo, Usman H Malabu et al. Lower extremity amputations and long-term outcomes in diabetic foot ulcers: A systematic review. 2020 Sep 15;11 9 391 399.2020 Sep 15;11 9 391 399. Open 4. Ayeshmanthe Rathnayake, Apoorva Saboo, Usman H Malabu et al. Lower extremity amputations and long-term outcomes in diabetic foot ulcers: A systematic review. World J Diabetes. 2020 Sep 15; 11 9 391 399. Open https://web.pathway.md/diseases/reclc5w1ab3TVTyjg 2/2