Beyond Neuropathy: The Mechanisms and Phenotypes of Diabetes-Related Musculoskeletal Pain

Diabetes Mellitus (DM) is a major global health concern associated with serious complications, high healthcare costs, and reduced quality of life. Musculoskeletal pain is a common complication and contributes to limitations in daily activities and increased healthcare utilization. Pain is a multidimensional phenomenon typically classified as nociceptive, neuropathic, or nociplastic; however, evidence regarding pain mechanisms and phenotypes in people with DM remains limited. This review aimed to synthesize and critically review the literature on musculoskeletal pain in individuals with DM, focusing on pain mechanisms and phenotypes according to the International Association for the Study of Pain (IASP) classification. A narrative review with systematic search procedures examined the applicability of the seven clinical criteria proposed by the IASP for nociplastic pain to musculoskeletal pain phenotyping. Searches were conducted in PubMed and Web of Science from inception to December 2025. Evidence was analyzed according to the IASP nociplastic pain criteria to explore alignment with pain phenotyping approaches. Overall, the literature indicates that neuropathic pain mechanisms are relatively well documented and consistently reported in individuals with diabetes, while nociceptive musculoskeletal drivers are also described but with more limited and heterogeneous evidence. In contrast, evidence addressing hypersensitivity phenomena and other domains related to nociplastic pain remains scarce and is still emerging. This pattern suggests that current research on pain in people with DM remains focused on neuropathic mechanisms. Future research adopting standardized pain phenotyping frameworks is needed to support more precise and individualized pain management strategies in this population.