Superimposed entrapment neuropathy in diabetes: Evidence review and algorithm for referral decisions

Diabetic peripheral neuropathy (DPN) is common, disabling, and associated with substantial risk of foot ulceration and lower extremity complications. A subset of patients develops superimposed peripheral nerve entrapment, which can exacerbate pain, impair protective sensation, and contribute to microcirculatory dysfunction. Although surgical decompression has been studied for more than three decades, awareness of entrapment features remains low in primary care, and guidance on patient selection is limited. This review summarizes current evidence on the clinical identification of focal nerve compression in patients with DPN and evaluates outcomes of decompression in appropriately selected patients. Across randomized controlled trials and observational studies, decompression is associated with reductions in neuropathic pain, improvements in selected sensory measures, and lower recurrence of neuropathic foot ulcers in patients who exhibit clinical features of entrapment. Based on this evidence, we propose a structured clinical algorithm to support primary care clinicians in identifying potential candidates for surgical evaluation. The algorithm emphasizes confirmation of DPN, screening for characteristic entrapment findings, assessment of prognostic indicators, optimization of conservative care, and appropriate referral. This approach aims to improve recognition of superimposed compression neuropathy and to provide practical guidance for evaluation and referral within primary care settings.