Differential Diagnosis

The patient's symptoms of bilateral nerve burning, numbness, and achiness in the knees and thighs, along with occasional involvement of the shins, calves, and right shoulder, suggest a complex neurological condition. The symptoms worsening with touch and the presence of some fatigue and reflex abnormalities guide the differential diagnosis.

• Single Most Likely Diagnosis

  • Peripheral Neuropathy: This condition is characterized by damage to the peripheral nerves, often causing burning, numbness, and pain, typically in a bilateral and symmetrical pattern. The symptoms can be exacerbated by pressure or touch, as seen with the patient's experience with clothing and bedding. The long-standing nature of the symptoms since 2012 also supports this diagnosis.

• Other Likely Diagnoses

  • Allodynia: As the patient has mentioned, allodynia is a condition where non-painful stimuli are perceived as painful. Given the patient's experience of burning sensations with light touch from clothing, this could be a contributing factor to their symptoms.
  • Fibromyalgia: Characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues, fibromyalgia could explain the patient's widespread pain and fatigue. However, the specific distribution of symptoms and the reflex findings might not fully align with typical fibromyalgia presentations.
  • Diabetic Neuropathy: Although not directly mentioned, if the patient has diabetes or prediabetes, diabetic neuropathy could be a cause of their symptoms. It typically presents with similar symptoms of burning, numbness, and pain in the extremities.

• Do Not Miss Diagnoses

  • Multiple Sclerosis (MS): MS is an autoimmune disease that affects the brain and spinal cord, leading to a wide range of neurological symptoms. While less likely given the patient's specific symptom pattern, MS can cause numbness, pain, and fatigue. The asymmetrical shoulder pain and the long history without clear relapses or remissions make this less likely but not impossible.
  • Vitamin Deficiency (B12, etc.): Deficiencies in vitamins, particularly B12, can cause neuropathy. This is a critical diagnosis not to miss because it is treatable with supplementation.
  • Lyme Disease: In endemic areas, Lyme disease can cause neuropathic symptoms, including pain and numbness. The seasonal variation in symptoms could potentially align with the timing of tick exposure.

• Rare Diagnoses

  • Erythromelalgia: A rare disorder characterized by burning pain, heat, and redness in the hands and feet, though it can occasionally affect other areas. The patient's symptoms of burning, especially exacerbated by touch or pressure, might suggest this, but the typical presentation usually involves more prominent redness and heat.
  • Complex Regional Pain Syndrome (CRPS): Characterized by severe, burning pain at the site of an injury, CRPS can also involve sensitivity to touch. While the patient's symptoms could partially fit, the lack of a clear precipitating injury and the bilateral, somewhat symmetrical nature of the symptoms make this less likely.