What is the cause of my chronic neuropathic pain, which started in my heels, then affected my tibial nerve, and is accompanied by tightness in my calf and hamstring, occasional lower back pain, and constant upper back muscle soreness extending to my biceps, forearms, wrists, and fingers, which feel tingly?

Urgent Neurological Evaluation Required for Possible Radiculopathy or Systemic Neuropathy

You need immediate evaluation by a neurologist with nerve conduction studies and electromyography, as your bilateral ascending pattern of symptoms from feet to hands with associated back pain strongly suggests either lumbar and cervical radiculopathy, a systemic polyneuropathy, or potentially a metabolic/inflammatory condition that requires urgent diagnosis. 1, 2

Why This Requires Urgent Attention

Your symptom pattern is concerning for several reasons:

• Bilateral involvement starting distally (heels) and progressing proximally (calves, hamstrings, lower back, then upper back, arms, hands) suggests either multiple nerve root compression or a systemic neuropathic process 1, 2
• The combination of lower back pain with leg symptoms PLUS upper back pain with arm symptoms indicates potential involvement at multiple spinal levels (lumbar and cervical radiculopathy) 3, 4
• Three months of progressive symptoms means this is not resolving spontaneously and requires definitive diagnosis 1
• Tingling in fingers with forearm and wrist soreness could indicate cervical radiculopathy or peripheral nerve entrapment 5

Critical Diagnostic Steps You Need Now

Immediate Neurological Examination Required

You need assessment of:

• 10-g monofilament testing on your feet to assess protective sensation loss 1
• Pinprick sensation, temperature perception, vibration testing with 128-Hz tuning fork, and ankle reflexes to differentiate small-fiber versus large-fiber neuropathy 1
• Cervical and lumbar spine examination with specific nerve root tension testing 3, 4

Essential Laboratory Testing

Your physician must order:

• Fasting glucose and hemoglobin A1c (diabetes is the most common cause of bilateral neuropathy) 1, 6
• Vitamin B12 level, TSH, free T4 (treatable causes of neuropathy) 1
• Complete blood count 1
• Consider hepatitis B, C, HIV testing if risk factors present 1

Diabetic neuropathy is a diagnosis of exclusion—other treatable causes must be ruled out first. 1

Electrodiagnostic Studies Are Mandatory

Nerve conduction studies and electromyography should be ordered immediately because your symptoms are bilateral and ascending, which is atypical for simple mechanical back pain. 1, 5 These studies will:

• Differentiate axonal versus demyelinating neuropathy 1
• Distinguish radiculopathy from peripheral neuropathy 1
• Identify entrapment syndromes (carpal tunnel, cubital tunnel, tarsal tunnel) 5, 1

Most Likely Diagnoses Based on Your Pattern

Lumbar and Cervical Radiculopathy (Most Likely)

20-35% of patients with chronic back pain have neuropathic components, and lumbar radicular pain is the most common neuropathic pain syndrome. 3, 4

Your symptoms suggest:

• Lumbar radiculopathy causing heel pain, tibial nerve symptoms, calf/hamstring tightness, and lower back pain 3, 4
• Cervical radiculopathy causing upper back pain radiating to biceps, forearms, wrists, and fingers 3
• The proportion of neuropathic pain increases with distal radiation of symptoms (80% when pain reaches the foot in dermatomal distribution) 4

Systemic Polyneuropathy (Must Rule Out)

Your bilateral "stocking-glove" distribution could indicate:

• Diabetic peripheral neuropathy (most common systemic cause) 5, 1
• Metabolic disorders (thyroid disease, B12 deficiency) 1
• Inflammatory conditions requiring specific testing 5, 1

Treatment Cannot Begin Until Diagnosis Is Confirmed

If Radiculopathy Is Confirmed

First-line pharmacological treatment includes duloxetine, pregabalin, gabapentin, or tricyclic antidepressants (nortriptyline or desipramine)—NOT opioids. 1, 2, 6

• Duloxetine has moderate-strength evidence for neuropathic pain with numbness and tingling, requiring 3-4 months at therapeutic dose 2
• Gabapentin/pregabalin are options despite ASCO stating no recommendation can be made for established chemotherapy-induced neuropathy (different context than radiculopathy) 5, 2
• Physical activity has moderate evidence (Level IA) and should be started alongside medication 2

If Diabetic Neuropathy Is Confirmed

Glycemic optimization is the only disease-modifying intervention and must be targeted to individualized HbA1c goals 1, 6

However, no compelling evidence exists that glycemic control treats established neuropathic pain—only pharmaceutical interventions provide pain relief. 6

Concurrent Management Required

Over two-thirds of patients with painful neuropathy have anxiety and/or depression—these must be treated concurrently with pain management. 6

Critical Pitfalls to Avoid

• Do NOT assume this is simple mechanical back pain—bilateral ascending symptoms require systemic evaluation 1, 2
• Do NOT delay nerve conduction studies—asymmetric or bilateral symptoms mandate electrodiagnostic testing 1
• Do NOT start neuropathic pain medications empirically—diagnosis must be confirmed first to avoid missing treatable causes 1
• Do NOT accept "wait and see" approach—three months of progressive symptoms requires definitive workup 1
• Up to 50% of diabetic peripheral neuropathy is asymptomatic initially—screening is mandatory even if you feel your symptoms are "just mechanical" 1

Imaging Considerations

Lumbar and cervical spine MRI should be considered if radiculopathy is suspected clinically, particularly given your combination of lower and upper extremity symptoms with corresponding back pain 3, 7. However, electrodiagnostic studies should be performed first to guide imaging decisions 1.