What you can't feel can hurt you.

Throughout our medical training, we are taught how to manage patients who present with symptoms, which usually leads to a clinical examination, a diagnosis, and a management plan. However, virtually no time is spent on teaching how to manage patients who have no symptoms because they have lost the ability to feel pain; that is, they have peripheral neuropathy. The lifetime incidence of foot ulceration in people with diabetes has been estimated to be as high as 25%, and a number of contributory factors result in a foot being at risk of ulceration. Most important amongst these factors is peripheral neuropathy, or the loss of the ability to feel pain, temperature, or pressure sensation in the feet and lower legs. Up to 50% of older patients with type 2 diabetes have evidence of sensory loss that puts them at risk of foot ulceration. If we are to succeed in reducing the high incidence of foot ulcers, regular screening for peripheral neuropathy is vital in all patients with diabetes. Those found to have any risk factors for foot ulceration require special education and more frequent review, particularly with podiatrists. The key message is therefore that neuropathic symptoms correlate poorly with sensory loss, and their absence must never be equated with lack of risk of foot ulceration. If we are to succeed in reducing the high incidence of foot ulceration and, particularly, recurrent ulceration, we must realize that with loss of pain there is also diminished motivation in the healing and the prevention of injury.