Differential Diagnosis: Peripheral Neuropathy vs. Peripheral Artery Disease
Your symptoms of bilateral tingling in the lower legs and feet with heavy walking and burning in both arms are most consistent with peripheral neuropathy, particularly if you have diabetes, vitamin deficiencies, or other metabolic conditions. 1
Key Distinguishing Features
Peripheral Neuropathy (Most Likely)
- Bilateral and symmetrical distribution affecting both legs/feet and potentially arms in a "stocking-glove" pattern, progressing from distal to proximal 1
- Burning pain, tingling (paresthesias), and "electrical shock" sensations are hallmark neuropathic symptoms 1, 2
- Symptoms often worse at night with severe sleep disturbance 2
- The heavy feeling when walking may represent leg weakness or fatigue rather than true claudication 3
- Physical examination typically shows minimal objective findings despite distressing symptoms 4
Peripheral Artery Disease (Less Likely Based on Your Description)
- Would cause cramping or aching pain (not burning/tingling) in buttocks, thighs, or calves 3
- Symptoms should be consistently triggered by walking and relieved within 10 minutes of rest 3
- Would not explain bilateral arm burning 3
- Physical exam would show decreased or absent pulses in feet 1
Essential Diagnostic Workup
Immediate laboratory testing should include: 1
- HbA1c and fasting glucose (diabetic neuropathy affects up to 50% of diabetics)
- Vitamin B12 levels (common reversible cause)
- Serum electrolytes including calcium and magnesium
- Complete metabolic panel
Neurological foot examination must assess: 1
- 10-gram monofilament testing for protective sensation
- Pinprick and temperature sensation
- Vibration sense
- Ankle reflexes
- Foot deformities and skin integrity
Critical Red Flags Requiring Urgent Evaluation
Seek immediate medical attention if you develop: 5, 6
- Acute onset (within days) or rapidly progressive symptoms
- Asymmetric symptoms or weakness
- Urinary retention or bowel dysfunction (suggests spinal cord involvement)
- Severe motor weakness in legs or arms
- Symptoms radiating from back down legs (may indicate spinal stenosis or myelopathy)
Most Common Causes to Consider
1. Diabetic Peripheral Neuropathy (Most Common)
- Affects up to 50% of diabetic patients 1
- Presents with burning feet, tingling, and uncomfortable sensations 2
- Small fiber dysfunction causes the burning quality 2
2. Vitamin B12 Deficiency
- Common and reversible cause 1
- Can affect both upper and lower extremities
3. Metabolic/Electrolyte Disturbances
- Calcium or magnesium imbalances can cause cramping and paresthesias 1
4. Cervical Myelopathy (If Arm Symptoms Predominate)
- Can cause arm burning with leg weakness and numbness 5
- May occur with congenital cervical stenosis even without trauma
- Requires urgent MRI if suspected
Initial Management Approach
While awaiting diagnostic workup: 2
- Avoid tight shoes or shoes with rough edges
- Inspect feet daily for injuries (especially if sensation is reduced)
- Use lubricating creams for dry skin
- Avoid walking barefoot
- Do not use ice water immersion despite burning sensation (risk of tissue damage) 2
If neuropathy is confirmed, first-line medications include: 1, 2
- Pregabalin, duloxetine, or gabapentin for neuropathic pain
- Tricyclic antidepressants as alternative
Non-pharmacologic interventions: 1
- Structured exercise programs
- Physical activity as tolerated
- Proper footwear for those with sensory loss
When to Refer to Specialists
Referral to foot care specialist or neurologist is indicated for: 1
- Severe neuropathy with loss of protective sensation
- Foot deformities or structural abnormalities
- History of ulceration
- Inadequate response to initial management
- Uncertain diagnosis requiring nerve conduction studies