What is the best course of action for a patient with long-standing, non-bothersome tingling in the feet, exacerbated by pressure from tight shoes or socks, and without associated pain?

Management of Long-Standing, Non-Bothersome Foot Tingling

The best course of action is to perform a comprehensive diabetic foot screening examination now, including assessment for peripheral neuropathy using monofilament testing, tuning fork vibration testing, and evaluation of pedal pulses, followed by patient education on proper footwear and daily foot inspection, even though the patient declined podiatry referral. 1

Immediate Clinical Assessment Required

This patient's symptoms—tingling in the feet exacerbated by pressure from tight shoes or socks, described as "walking on a different surface"—are classic early manifestations of peripheral neuropathy that warrant systematic evaluation, regardless of whether they are currently bothersome. 2

Essential Screening Components

You should perform the following assessments at this visit:

• Neuropathy testing using Semmes-Weinstein 10-g monofilament for pressure perception, 128-Hz tuning fork for vibration perception, and pin prick testing on the dorsum of the foot 1
• Vascular assessment including palpation of pedal pulses and consideration of ankle-brachial index (ABI) if pulses are diminished, as many patients with peripheral artery disease are asymptomatic 1
• Skin inspection for callus formation, color changes, temperature differences, and areas between the toes 1
• Footwear examination of both the inside and outside of shoes currently worn at home and outside 1
• Assessment for foot deformities such as hammertoes, prominent metatarsal heads, or bunions that may require accommodative footwear 1

The absence of pain does not exclude significant pathology—approximately 20% of asymptomatic individuals with diabetes have abnormal cardiovascular autonomic function, and neuropathy often precedes other diabetic complications. 3

Risk Stratification and Follow-Up Frequency

Based on the IWGDF Risk Classification System, determine the patient's category:

• Category 0 (no peripheral neuropathy): Annual screening 1
• Category 1 (peripheral neuropathy present): Every 6 months 1
• Category 2 (neuropathy plus peripheral artery disease or foot deformity): Every 3-6 months 1
• Category 3 (neuropathy plus history of ulcer or amputation): Every 1-3 months 1

Critical Patient Education—Implement Immediately

Even without podiatry referral, you must provide structured foot care education now:

Footwear Instructions

• Instruct the patient to avoid tight socks or shoes immediately, as pressure exacerbates her symptoms and can lead to tissue damage in neuropathic feet 1
• Prohibit walking barefoot, in socks only, or in thin-soled slippers both at home and outside, as this is a major cause of foot ulceration in at-risk patients 1
• Recommend wearing socks without seams (or with seams inside out) and changing socks daily 1
• Instruct to inspect inside all shoes before wearing them 1

Daily Self-Care Protocol

• Daily foot inspection including areas between the toes, or arrange for a family member to assist if the patient cannot adequately visualize her feet 1
• Wash feet daily with water temperature below 37°C and dry carefully, especially between toes 1
• Apply emollients to lubricate dry skin but not between the toes 1
• Notify healthcare provider immediately if foot temperature is markedly increased or if blisters, cuts, or ulcers develop 1

Ultrasound Assessment Consideration

While the patient is open to ultrasound assessment, this is not the appropriate initial diagnostic approach for suspected peripheral neuropathy. The clinical examination with monofilament, tuning fork, and pin prick testing provides the necessary diagnostic information. 1 Ultrasound may be useful later if specific structural foot abnormalities or soft tissue masses are suspected, but should not replace the standard neuropathy screening.

Common Pitfalls to Avoid

• Do not dismiss non-bothersome symptoms as insignificant—peripheral neuropathy in diabetes is typically length-dependent and progresses proximally over time, and early detection allows for preventive interventions 2
• Do not delay screening because the patient declined podiatry referral—you can perform the essential screening tests in your office and provide critical education now 1
• Do not focus solely on neurological assessment without vascular evaluation—many foot ulcers are neuro-ischemic, caused by combined neuropathy and ischemia, and symptoms may be absent despite severe pedal ischemia 1
• Do not wait for symptoms to become bothersome—up to 18.9% of patients attending diabetic screening have never had their feet examined, and early intervention prevents progression to high-risk foot status 4

When to Escalate Care

Refer to podiatry or vascular surgery if you identify:

• Loss of protective sensation on monofilament testing 1
• Absent or diminished pedal pulses or ABI <0.90 1
• Foot deformities requiring custom-molded shoes 1, 5
• Pre-ulcerative signs such as callus with underlying erythema or hemorrhage 1
• Failure to improve with conservative footwear modifications 5

The patient's openness to ultrasound suggests willingness to engage with diagnostic testing, which you can leverage to encourage appropriate follow-up and eventual podiatry consultation if screening reveals significant neuropathy or vascular compromise. 4