Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle, Howell & Bloomfield Hills, MI
Last reviewed: May 2026
Balance Foot & Ankle offers same-day appointments for urgent foot and ankle conditions across Southeast Michigan — but the most important factor in outcomes isn’t getting seen quickly. Our podiatrists explain what to do in the first 24-48 hours before your appointment that most patients skip entirely. Call (810) 206-1402 — expert podiatric care across Michigan.
| Neuropathy Type | Fiber Type Affected | Symptoms | Clinical Test | Risk | Distinction |
|---|---|---|---|---|---|
| Diabetic Peripheral Neuropathy (DPN) | Small fiber (pain/temp) first; large fiber (vibration/proprioception) later | Burning, numbness, tingling stocking distribution; worse at night | 10g monofilament (loss = high ulcer risk); vibration 128 Hz tuning fork | Ulceration; Charcot; amputation | Symmetric; distal → proximal; bilateral “stocking” pattern |
| Tarsal Tunnel Syndrome | Posterior tibial nerve — all fibers | Burning / electric into plantar foot and toes; often unilateral | Tinel’s sign over tarsal tunnel; EMG/NCS confirms | Nerve damage if untreated; less ulcer risk | Unilateral; proximal to distal compression; Tinel’s present |
| Charcot-Marie-Tooth (CMT) | Large fiber motor + sensory | Foot deformity (cavus); weakness; peroneal muscle wasting; family history | EMG/NCS: demyelinating or axonal pattern; genetic testing | Progressive deformity; not ulceration primarily | Motor prominent; cavus foot; young onset; family history |
| Peripheral Arterial Disease (PAD) | Not neuropathy — ischemia | Cold feet; claudication; rest pain; wounds not healing | ABI <0.9; toe pressures; Doppler | Critical limb ischemia; gangrene; amputation | Vascular not neurologic; ABI diagnostic; wounds typically distal |
| Vitamin B12 Deficiency Neuropathy | Large fiber; posterior column | Numbness; loss of vibration; gait instability; may mimic DPN | Serum B12 / methylmalonic acid; MRI (subacute combined degeneration) | Irreversible if untreated | Reversible with B12 supplementation if caught early; check in metformin users |
| Intervention | Target | Evidence | Effect on Neuropathy | Notes |
|---|---|---|---|---|
| Glycemic Control (A1C <7%) | Halts progression; may improve symptoms | DCCT: intensive control reduces DPN incidence 60% in Type 1 | Prevents worsening; partial reversal in early DPN | Most important single intervention; refer to endocrinology if A1C >8% |
| Pregabalin (Lyrica) | Neuropathic pain | Level I — FDA-approved for DPN; NNT ~4 | 30–50% pain reduction in responders | Titrate to 300 mg/day; side effects: dizziness, weight gain, edema |
| Duloxetine (Cymbalta) | Neuropathic pain | Level I — FDA-approved for DPN; NNT ~5 | 50% pain reduction in 45–50% of patients | First-line if depression or anxiety co-present; 60 mg/day target |
| Tricyclic Antidepressants (Amitriptyline) | Neuropathic pain | Level II — widely used off-label | Moderate pain reduction; NNT ~3 | Low-dose 10–75 mg nightly; use caution in cardiac disease and elderly |
| Custom Diabetic Orthotics + Extra-Depth Shoes | Ulcer prevention; pressure redistribution | Level I — reduces plantar pressure 30–50% | Reduces ulceration risk; does not treat pain | Medicare covers annual diabetic shoe benefit; total contact casting for active ulcers |
| Regular Podiatric Foot Exams (quarterly) | Early detection; wound prevention | ADA standard of care | Reduces amputation risk 40–60% | Loss of protective sensation on monofilament = quarterly exam; annual if intact |
Watch: Peripheral Neuropathy Home Remedies [Leg & Foot Nerve Pain Treatment] — MichiganFootDoctors YouTube
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Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Diabetic peripheral neuropathy (DPN) is the silent threat to the diabetic foot. When peripheral sensation is lost — even partially — the foot loses its most important protective mechanism: pain. A patient with DPN can develop a blister from a poorly fitting shoe, walk on it for days until it ulcerates, develop a bone infection (osteomyelitis), and require amputation — all without ever feeling more than vague discomfort. Dr. Biernacki at Balance Foot & Ankle has structured his entire diabetic foot care program around this reality: prevention is everything, and prevention requires consistent, thorough podiatric surveillance.
Annual Comprehensive Diabetic Foot Exam
The Medicare Annual Diabetic Foot Exam is not a routine wellness visit — it is a systematic clinical assessment of all risk factors for diabetic foot complications. Dr. Biernacki’s DPN exam protocol includes: Semmes-Weinstein 10-gram monofilament testing at 10 plantar sites bilaterally — the gold standard for detecting loss of protective sensation (LOPS). Vibration perception threshold testing with 128-Hz tuning fork at the first MTPJ and medial malleolus. Ankle-brachial index (ABI) measurement to screen for peripheral arterial disease (PAD) — often coexisting with neuropathy and dramatically worsening ulcer healing potential. Vascular assessment: palpation of dorsalis pedis and posterior tibial pulses; capillary refill time; skin color and temperature. Dermatologic assessment: fissures, calluses (pre-ulcerative lesions), tinea pedis, onychomycosis, and any skin breakdown. Musculoskeletal assessment: deformity documentation (hammertoes, bunions, Charcot changes), range of motion, and gait assessment. Footwear evaluation: assessing current shoes for fit, wear patterns, and appropriateness.
The Medicare Therapeutic Shoe Program
The Medicare Therapeutic Shoe Program (TSP) is one of the most cost-effective preventive health benefits in Medicare — and one of the most underused. Qualifying diabetic patients receive annually: 1 pair of custom-molded or extra-depth therapeutic shoes and 3 pairs of custom-molded insert insoles. Eligibility requires: Medicare Part B, diabetes diagnosis, documentation of at least one of — peripheral neuropathy, peripheral vascular disease, history of plantar ulceration, foot deformity (bunions, hammertoes, Charcot), or pre-ulcerative callus. Dr. Biernacki performs the required physician certification, conducts the prescribing exam, and coordinates fitting with a certified pedorthist. Therapeutic shoes reduce plantar pressure at-risk sites by 30–50% compared to standard footwear — a significant ulcer prevention benefit.
Patient Education: The Daily Foot Inspection Protocol
Every DPN patient receives comprehensive self-care education from Dr. Biernacki’s team. The daily foot inspection protocol includes: inspect all surfaces of both feet each morning and evening — use a mirror or family member for plantar surfaces; check between toes for maceration or ulceration; feel for areas of warmth (inflammatory sign) using the back of the hand; report any skin break, blister, redness, or swelling immediately without waiting to see if it resolves. Footwear rules: always wear shoes or diabetic slippers — never barefoot; shake out shoes before putting on (foreign objects cause pressure injury); break in new shoes gradually. Nail care: cut nails straight across, never cut corners; if vision or mobility impairs safe nail trimming, podiatric nail care visits are covered services.
Wound Care When Breakdown Occurs
Despite best preventive efforts, some DPN patients develop plantar ulcers. Dr. Biernacki’s wound care protocol for diabetic neuropathic ulcers includes: wound staging using the Wagner or UT classification system; ABI measurement to assess vascular status and healing potential; wound culture for infected ulcers; total contact casting (TCC) — the gold standard offloading method, reducing plantar pressure by 85–90% and achieving healing in 90% of Wagner Grade 1 ulcers; sharp wound debridement to remove callus and non-viable tissue; appropriate antimicrobial dressings; and vascular surgery referral for wounds with ABI <0.6. The goal is complete wound closure — the most important predictor of long-term limb salvage.
Dr. Tom's Product Recommendations
Dr. Comfort Men’s Endmill Diabetic Walking Shoe
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Extra-depth diabetic shoe with removable insole to accommodate custom orthotics. Seamless interior eliminates pressure points — essential daily protective footwear for diabetic neuropathy patients.
Dr. Tom says: “”My podiatrist put me in Dr. Comfort shoes after my DPN diagnosis. No more hot spots or blisters from my old shoes.””
Diabetic neuropathy patients who qualify for Medicare Therapeutic Shoe Program
Patients with active foot ulcers — specialized wound care footwear required instead
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Powerstep Pinnacle Maxx Diabetic Insoles — Full Length
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Pressure-redistributing insoles with firm arch support for diabetic neuropathy patients. Reduces plantar pressure at high-risk areas (metatarsal heads, heel) that neuropathic patients cannot monitor by sensation.
Dr. Tom says: “”My podiatrist recommended arch support insoles inside my diabetic shoes. The combination has kept my feet ulcer-free for 3 years.””
Diabetic neuropathy patients needing pressure redistribution inside diabetic or therapeutic shoes
Patients with active plantar ulcers — total contact casting or offloading boot required
Disclosure: We earn a commission at no extra cost to you.
✅ Pros / Benefits
- Annual comprehensive DPN exam identifies risk factors before ulceration occurs
- Medicare Therapeutic Shoe Program provides annual diabetic shoes — underused but highly effective
- Total contact casting achieves 90% healing in neuropathic plantar ulcers
❌ Cons / Risks
- Neuropathy itself is not reversible — management prevents complications, not the underlying nerve damage
- Annual exam compliance is the key determinant of outcomes — missed exams allow problems to progress silently
- TCC requires weekly clinic visits for 6–12 weeks — significant time commitment for wound healing
Dr. Tom Biernacki’s Recommendation
If there’s one message I want every diabetic patient in Michigan to hear, it’s this: diabetic foot complications are not inevitable — they’re largely preventable with consistent podiatric care. Annual exams, therapeutic shoes, and daily foot inspection aren’t optional extras; they’re the difference between keeping your foot and losing it. Michigan has one of the highest diabetes rates in the country. My practice exists in large part to help diabetic patients stay ahead of foot complications that could devastate their quality of life.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
How often should diabetics see a podiatrist?
Minimum once annually for a comprehensive diabetic foot exam — Medicare covers this as a preventive benefit for qualifying diabetic patients. Patients with established neuropathy, vascular disease, or prior ulceration should be seen every 1–3 months for preventive care and monitoring. Patients with active wounds are seen weekly or more frequently.
What is a Semmes-Weinstein monofilament test?
It’s a simple, painless test using a 10-gram nylon filament pressed against 10 sites on the plantar surface of each foot. If you cannot feel the filament at 4+ sites, you have clinically significant loss of protective sensation (LOPS) — the major risk factor for ulceration. The test takes about 3 minutes and is performed at every diabetic foot exam.
Does Medicare cover diabetic foot care?
Medicare Part B covers annual comprehensive diabetic foot exams. For patients with documentation of diabetes and relevant complications (neuropathy, vascular disease, history of ulceration, deformity), the Medicare Therapeutic Shoe Program provides annual custom-fitted shoes and insoles. Routine nail care is covered only for specific documented conditions — check with our office regarding your eligibility.
I have numbness in my feet but no open sores. Do I still need to see a podiatrist?
Absolutely yes — this is exactly the right time to establish podiatric care. Numbness (neuropathy) is the warning sign that your feet can no longer protect themselves. Establishing care before a wound develops allows us to identify risk factors, provide therapeutic footwear, educate on self-care, and catch early skin changes before they progress to ulcers.
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When should I see a podiatrist?
If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).
What does treatment cost?
Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.
How quickly can I get an appointment?
Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.
In-Office Treatment at Balance Foot & Ankle
If home treatment isn’t providing relief for your neuropathy, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.
American Podiatric Medical Association: Neuropathy
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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.