Case Overview
Recently, in a First Contact Physiotherapy (FCP) clinic, I assessed a 75-year-old gentleman presenting with numbness in both of his feet. He had been a type 2 diabetic for 20 years, although his HbA1c levels indicated well-controlled blood sugar.
He also reported low back pain and unilateral posterior thigh pain, which worsened with walking and improved with sitting or leaning forward.
Initial Assessment and Hypothesis
My primary hypothesis was diabetic neuropathy, given his long-standing diabetes and neuropathic symptoms.
However, his lumbar spine and radicular symptoms, alongside the pattern of aggravating and easing factors, suggested the possibility of spinal stenosis. To rule this out, I ordered a lumbar MRI.
The MRI report excluded significant nerve root compression or canal stenosis, supporting the likelihood of diabetic neuropathy as the cause of his symptoms.
Using OpenAthens and Evidence-Based Guidelines
As a physiotherapist in secondary care, diagnosing diabetic complications was not something I encountered regularly. In primary care, patients with neuropathic symptoms due to diabetes are more commonly triaged to the MSK FCP clinic.
Using my OpenAthens account, I accessed the BMJ Best Practice guidelines to confirm whether further investigations were necessary before confidently diagnosing diabetic neuropathy.
Key Findings from BMJ Best Practice
The BMJ guidelines provided clear, evidence-based guidance:
Diabetic neuropathy can be diagnosed after excluding other likely causes.
Nerve conduction studies are generally not required unless clinical features are atypical
It is the most common complication of diabetes, particularly in individuals:
Over 70 years old
With long-standing diabetes (more than 10 years)
With poorly controlled hyperglycaemia
With increased height
This information allowed me to confidently attribute the patient’s symptoms to diabetic neuropathy, without unnecessary tests.
Reflection
This experience highlighted the importance of reliable, evidence-based resources in primary care practice. OpenAthens and BMJ Best Practice provided quick access to up-to-date guidance, enabling a safe, accurate, and confident diagnosis.
It also reinforced the value of considering both common and less obvious causes when assessing neuropathic symptoms, particularly in older patients with complex medical histories.
How to access Knowledge and Library Services
NHS Knowledge and Library Services gives you access to the most up to date and trusted evidence and information in healthcare today. It enables high quality decision making, professional development, research and innovation to achieve health improvement. To take full advantage of all the tools and resources, you first need to create an OpenAthens account.
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