What is the diagnosis for a diabetic adult with no sensation in the heels bilaterally but normal sensation in other areas on a monofilament test?

Loss of Protective Sensation (LOPS) in the Heels

This clinical finding is called "Loss of Protective Sensation" (LOPS), specifically affecting the heel distribution, which represents a focal pattern of diabetic peripheral neuropathy that places the patient at high risk for heel ulceration. 1, 2

What This Finding Means

The monofilament test is specifically designed to identify LOPS rather than diagnose early neuropathy—it detects patients who have lost the ability to feel pressure that would normally protect them from injury. 1, 2 When only the heels show absent sensation bilaterally while other plantar sites remain normal, this represents:

• A focal distribution of LOPS affecting the heel region specifically 1
• High risk for heel ulceration since the patient cannot feel trauma, pressure, or developing wounds in this area 3
• Confirmation that protective sensation is preserved in other foot areas (metatarsal heads, toes, arch) where testing was normal 1

Diagnostic Confirmation

You should confirm this diagnosis by performing at least one additional sensory test, as the American Diabetes Association recommends combining monofilament testing with another modality: 1

• Vibration testing with a 128-Hz tuning fork at the heel to assess large-fiber function 1
• Pinprick sensation to evaluate small-fiber function 1
• Temperature sensation testing 1
• Ankle reflexes assessment 1

The diagnostic algorithm states that absent monofilament sensation alone suggests LOPS, but at least two normal tests with no abnormal tests would rule it out—so additional testing helps confirm the focal nature of this finding. 1, 2

Clinical Significance and Risk Stratification

This focal heel LOPS has critical management implications:

• The heel is a weight-bearing surface where insensate patients develop pressure ulcers, particularly if bedridden or using poorly fitted footwear 1
• 78% of diabetic foot ulcers occur in patients with LOPS, making this finding a major risk factor 3
• This patient requires immediate risk stratification as someone with LOPS who needs specialized preventive care 1

Immediate Management Steps

Refer this patient to a foot care specialist for ongoing preventive care and lifelong surveillance, as recommended for anyone with loss of protective sensation. 1 Specific interventions include:

• Specialized therapeutic footwear with heel cushioning to redistribute pressure away from insensate areas 1
• Daily foot inspection education focusing on the heels, since the patient cannot feel developing problems 3
• Pressure off-loading strategies if the patient has limited mobility or spends extended time with heel pressure 1
• More frequent monitoring intervals (not just annual) given the focal high-risk area 1

Common Pitfalls to Avoid

Do not assume this represents generalized diabetic neuropathy—the focal heel distribution is unusual and warrants careful documentation. 1 The typical pattern of diabetic neuropathy affects the toes and forefoot first in a "stocking" distribution, so isolated heel involvement may suggest: 1

• Pressure-related nerve damage from prolonged heel contact
• Focal nerve compression or entrapment
• Early LOPS that will progress to other sites over time

Do not delay referral to podiatry while waiting for progression—the current finding already qualifies this patient as high-risk requiring specialized footwear and preventive strategies. 1, 3

Documentation and Follow-Up

Document this as "Loss of Protective Sensation, bilateral heels" with preserved sensation at other plantar sites tested. 1 Schedule comprehensive foot examinations more frequently than annually given the identified LOPS, and ensure the patient understands they cannot rely on pain or discomfort to alert them to heel injuries. 1, 3