Symptoms of diabetic peripheral neuropathy

Diabetic peripheral neuropathy is commonly defined by the presence of peripheral nerve dysfunction in people with diabetes after exclusion of other causes.^1,2

Diabetic peripheral neuropathy symptoms and signs vary depending on the type of nerve fibers affected.³ While pain is a common symptom, not all patients experience it, and some individuals may be asymptomatic.³

Small-fiber symptoms and signs

Small-fiber damage can cause pain, which may manifest as stabbing, burning or electric shock-like sensations.³ It often emerges during the early stages of diabetic peripheral neuropathy and tends to worsen at night.³

Pain may be accompanied by dysesthesias, such as hyperalgesia and allodynia.³ Hyperalgesia refers to abnormally increased pain sensitivity to a stimulus that normally provokes pain,^4,5 while allodynia refers to pain due to a stimulus that does not normally provoke pain.^4,5

Upon clinical examination, patients may also display characteristic signs of small-fiber damage such as reduced or absent response to thermal discrimination and pinprick sensation testing.³

Learn more about diagnostic assessments of peripheral nerve dysfunction in people with diabetes after exclusion of other causes.^1,2

Large-fiber symptoms and signs

Damage to large fibers can result in symptoms such as numbness and tingling sensations without pain.³ In advanced stages of diabetic peripheral neuropathy, patients may also experience poor balance and muscle weakness.^3,6

Clinical signs of large fiber damage include impaired proprioception and reduced or absent response to several diagnostic tests such as ankle reflexes, vibration perception, and 10-g monofilament sensation.³

Asymptomatic diabetic peripheral neuropathy

Up to 50% of patients with diabetic peripheral neuropathy may be asymptomatic or reluctant to report symptoms.³

Some patients, initially aware of neuropathic symptoms, may become asymptomatic with time due to severe sensory loss in nerve fibers, which can result in insensate feet.³

Distal to proximal progression of diabetic peripheral neuropathy

Progression of diabetic peripheral neuropathy most often starts in the toes and gradually moves proximally. Once established in the lower limbs, it can begin to affect upper limbs as well.⁸

A distal-to-proximal loss of sensory fibers (axonal loss), with accompanying “stocking and glove” pattern of symptoms, are the hallmark of diabetic peripheral neuropathy.^3,8

Distal-to-proximal progression of diabetic peripheral neuropathy<sup>3,8</sup>

Distal-to-proximal progression of diabetic peripheral neuropathy^3,8

Recognition of early symptoms and signs, and timely interventions are crucial to preventing the progression of diabetic peripheral neuropathy and complications.⁹ Learn more about diagnosising diabetic peripheral neuropathy.

About DPN

Diagnosis

Footnotes

Boulton AJ et al. Diabet Med. 1998;15:508–14.
Pop-Busui R et al. Diabetes Care. 2017;40:136–54.
Pop-Busui R et al. Diagnosis and treatment of painful diabetic peripheral neuropathy. Arlington (VA): American Diabetes Association; 2022. https://www.ncbi.nlm.nih.gov/books/NBK580224/. Accessed May 21, 2025.
Bannister K et al. Annu Rev Pharmacol Toxicol. 2020;60:257–74.
International Association for the Study of Pain (IASP). 2021. Terminology. https://www.iasp-pain.org/resources/terminology/. Accessed May 21, 2025.
Feldman EL et al. Nat Rev Dis Primers. 2019;5:42.
de Souza RJ et al. J Diabetes Complications. 2015;29:811–7.
Tesfaye S, Selvarajah D. Diabetes Metab Res Rev. 2012;28(Suppl 1):8–14
Gandhi M et al. Drugs Context. 2022;11:2021-10-2.

N/A-05-25-0007 | June 2025