Reevaluating the Stocking Distribution Pattern in Diabetic Peripheral Neuropathy

Background: This study evaluates the prevalence and spatial distribution of sensory loss in individuals with diabetes using standardized monofilament testing. Specifically, it examined the frequency of the classically described axonal length-dependent, symmetric, "stocking" pattern of sensory impairment and tested whether this presentation is universally observed in diabetic peripheral sensory neuropathy. Methods: Consecutive patients with an established diagnosis of diabetes were screened at a rural clinic. Each leg was assessed using a 10-gram monofilament applied to standardized quadrants of the foot while the patient was visually blinded to the stimulus location. Any sensory loss was recorded and categorized based on its symmetry and anatomical distribution. Additional variables collected included sex, age, diabetes type and duration, height, weight, body mass index, and most recent hemoglobin A1c. Results: Among 549 individuals (1,098 limbs), the prevalence of any sensory loss was 69.8%. Of those with sensory loss symmetric sensory loss was observed in 36.3% of individuals, while a stocking distribution pattern was present in only 15.9%. Statistical analysis showed that height, hemoglobin A1c, and body mass index were independently associated with stocking-pattern sensory loss, with height having the strongest effect size. Conclusions: Although sensory loss is common in individuals with diabetes, the classical stocking distribution pattern is less prevalent than traditionally portrayed. These findings suggest that the standard clinical model may overstate the universality of this presentation and support the need for a more individualized approach to neuropathy assessment. This calls into question the reliance on stocking-pattern descriptors in clinical screening and underscores the need for site-specific sensory evaluation in routine diabetic foot exams.