A patient with type 2 diabetes and a burning sensation in his feet

A 64 year old man with type 2 diabetes diagnosed nine years earlier attended the outpatient diabetes clinic because of suboptimal diabetes control. His glycated haemoglobin over the past five years had been 64-77 mmol/mol (8-9.2%; optimal value <53 mmol/mol (7%)). He was being treated for diabetes with gliclazide and metformin. He also received simvastatin and enalapril for dyslipidaemia and hypertension, respectively, and 75 mg acetylsalicylic acid daily for the prevention of primary cardiovascular disease.

He had painful symptoms in his legs, which he described as a burning sensation, with tingling in the feet. He had been experiencing the burning pain for the past six months, especially during the night, and he had to walk about or put his feet in water to find relief. He thought that the symptoms may be related to poor circulation in his legs and he was worried that he might need an amputation.

On examination he could not feel the 128 Hz tuning fork up to his knees bilaterally or the 10 g Semmes-Weinstein monofilaments on two out of three sites on the plantar surface of his feet. Pedal pulses, however, were palpable in both feet.