Diabetic peripheral neuropathy can be painful. It can also be dangerously quiet. In either case, the opportunity to protect a foot begins long before an ulcer appears.
Our new review, Diabetic Peripheral Neuropathy: Implementing Guidelines into Practice, published October 9 in the Journal of the American Podiatric Medical Association, asks a practical question: How do we make evidence-based neuropathy care happen reliably in the places where people actually receive care?
The American Limb Preservation Society (ALPS) assembled our task force to bring existing recommendations into a usable clinical framework. The result is a review and implementation roadmap, with attention to screening, diagnosis, foot protection, pain management, referral, and continuity of care.
A multinational, multidisciplinary effort
This work brings together Lee C. Rogers, Brian D. Lepow, David G. Armstrong, Erika A. Petersen, Rodica Pop-Busui, Solomon Tesfaye, Shravani Durbhakula, and Robert G. Frykberg.
Our affiliations span the United States and United Kingdom: The University of Texas at San Antonio, Hope Clinic of Houston, USC’s Keck School of Medicine, the University of Arkansas for Medical Sciences, Oregon Health & Science University, Sheffield Teaching Hospitals NHS Foundation Trust, and Vanderbilt University. That range of expertise matters. Neuropathy care crosses the boundaries of foot care, diabetes medicine, surgery, neurosurgery, and pain medicine.
Three things to carry into clinic
1. Look for neuropathy before it announces itself. The ADA’s 2026 Standards of Care recommend assessment at diagnosis of type 2 diabetes, five years after diagnosis of type 1 diabetes, and at least annually thereafter. A history and examination should assess small- and large-fiber function. The 10-g monofilament remains important for identifying loss of protective sensation, but using it alone can miss earlier neuropathy.
Diabetes should also never end the diagnostic conversation. Other causes of neuropathy may be treatable. Rapid progression, asymmetry, prominent weakness, or diagnostic uncertainty should prompt further evaluation. Vascular disease deserves attention, too.
2. Turn the examination into a prevention plan. Loss of protective sensation, peripheral artery disease, deformity, previous ulceration or amputation, and kidney failure should change what happens next. Risk classification should determine follow-up, footwear, education, and referral. Daily foot inspection, appropriate footwear, and treatment of pre-ulcerative problems need to become part of the plan people can actually follow.
This connects directly with the ALPS message to “Save 2 Feet in 3 Minutes.” A brief examination can open the door to prevention. For people already at higher risk, the next appointment is part of that treatment plan.
3. Treat pain and protect function. Pain care should consider sleep, mood, daily activity, comorbidities, and treatment tolerability. The review discusses evidence-based oral therapies, topical options, and specialist referral when relief remains inadequate. The AAN guideline recommends effective nonopioid medication classes and advises against opioids for painful diabetic neuropathy.
For selected people with refractory painful neuropathy, spinal cord stimulation is among the specialist options discussed. The evidence and patient-selection requirements differ across treatments. Improvements in pain or sensory testing should not automatically be translated into claims of fewer ulcers or amputations.
The most practical part: make the pathway work
The implementation checklist may be the paper’s most immediately useful contribution. A clinic can start with four questions:
- Who owns each step? Agree on responsibilities for screening, education, referral, and follow-up, including the patient’s role.
- Where is the plan recorded? Use consistent documentation, risk categories, and prompts that fit the existing workflow.
- What happens after an abnormal finding? Establish referral routes with real appointment capacity and communication back to the treating team.
- How will we know care improved? Audit missed screening and delayed referrals, and track complications, quality of life, and patient experience.
Local resources matter. A well-designed rooming protocol, trained nursing or medical-assistant staff, and a dependable referral agreement may be more useful than another electronic alert that nobody has time to act on.
Keeping the evidence in perspective
This review does not report a new clinical trial or demonstrate that its proposed implementation pathway reduces amputations. It synthesizes existing guidance and evidence into practical suggestions that need evaluation and adaptation in real-world health systems. Treatment evidence varies, and the paper emphasizes continuing gaps in disease-modifying care for established neuropathy.
Find neuropathy early. Make the next step clear. Keep people connected to care. That is how a guideline begins to become limb preservation.
Read the paper
Rogers LC, Lepow BD, Armstrong DG, Petersen EA, Pop-Busui R, Tesfaye S, Durbhakula S, Frykberg RG. Diabetic Peripheral Neuropathy: Implementing Guidelines into Practice. J Am Podiatr Med Assoc. 2026;116(5):84. doi:10.3390/japma116050084. Open access.
Disclosure: The article reports no external funding. It also reports relevant author relationships with industry. My disclosures include service on the ALPS Board of Directors and advisory relationships with Podimetrics and Nevro. Readers can review the authors’ full disclosures in the paper.
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