How does distal symmetric painful polyneuropathy present clinically?
Distal symmetric painful polyneuropathy presents with paresthesias or burning in the feet in a symmetric distribution. Because it is length-dependent, the symptoms usually begin in the toes and progress proximally. Foot pain beginning in the instep, heels, or ankles is less likely to be neuropathic. Symptoms are commonly most severe at rest and in the evening. Although pain is often more severe after an active day, it is not generally precipitated by weight bearing, and pain that immediately develops upon standing or walking and improves promptly with sitting down is most likely to be mechanical foot pain rather than neuropathy pain. As noted previously, sensory loss is usually present, and many patients are aware of this. In almost all cases this is an indolently progressive disorder, with pain and sensory deficits progressing proximally very slowly over a matter of years, and often stabilizing with little detectable worsening within a few years of onset.