Video: Every Case Tells a Story| Webinar: ACR/CHEST ILD Guidelines in Practice

An official publication of the ACR and the ARP serving rheumatologists and rheumatology professionals

  • Conditions
    • Axial Spondyloarthritis
    • Gout and Crystalline Arthritis
    • Myositis
    • Osteoarthritis and Bone Disorders
    • Pain Syndromes
    • Pediatric Conditions
    • Psoriatic Arthritis
    • Rheumatoid Arthritis
    • Sjögren’s Disease
    • Systemic Lupus Erythematosus
    • Systemic Sclerosis
    • Vasculitis
    • Other Rheumatic Conditions
  • FocusRheum
    • ANCA-Associated Vasculitis
    • Axial Spondyloarthritis
    • Gout
    • Psoriatic Arthritis
    • Rheumatoid Arthritis
    • Systemic Lupus Erythematosus
  • Guidance
    • Clinical Criteria/Guidelines
    • Ethics
    • Legal Updates
    • Legislation & Advocacy
    • Meeting Reports
      • ACR Convergence
      • Other ACR meetings
      • EULAR/Other
    • Research Rheum
  • Drug Updates
    • Analgesics
    • Biologics/DMARDs
  • Practice Support
    • Billing/Coding
    • EMRs
    • Facility
    • Insurance
    • QA/QI
    • Technology
    • Workforce
  • Opinion
    • Patient Perspective
    • Profiles
    • Rheuminations
      • Video
    • Speak Out Rheum
  • Career
    • ACR ExamRheum
    • Awards
    • Career Development
  • ACR
    • ACR Home
    • ACR Convergence
    • ACR Guidelines
    • Journals
      • ACR Open Rheumatology
      • Arthritis & Rheumatology
      • Arthritis Care & Research
    • From the College
    • Events/CME
    • President’s Perspective
  • Search

Small Fiber Neuropathy for the Rheumatologist

Michael Cammarata, MD  |  Issue: January 2024  |  January 10, 2024

Small fiber neuropathy is a common form of peripheral neuropathy with multiple potential etiologies and a varied clinical presentation. It can’t be detected by nerve conduction studies, making it an elusive and often overlooked entity. Small fiber neuropathy is well documented in several rheumatic diseases, and its symptom burden can profoundly affect quality of life. Thus, rheumatologists should have the knowledge to suspect and evaluate for this condition in the clinic.1

In this article, we speak with Michael Polydefkis, MD, associate professor of neurology at Johns Hopkins University, Baltimore, where he collaborates with the Jerome L. Greene Sjögren’s Syndrome Center and has a particular interest in peripheral neuropathy. His expertise is in nerve conduction studies, electromyography, and nerve, skin and muscle biopsy. He shares his practical approach to the diagnosis and management of small fiber neuropathy with an emphasis on essential knowledge for both the community and academic rheumatologist.

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

Background

Peripheral nerve fibers can be broadly classified by nerve fiber diameter as small or large. Small fiber neuropathy is due to the destruction of the smaller, lightly myelinated A-delta and unmyelinated C fibers.2 Small fibers, the largest subset of peripheral nerves, include nociceptors and autonomic fibers. Damage to these often results in positive symptoms, such as pain, paresthesia (i.e., a burning or prickling sensation) and allodynia (i.e., extreme sensitivity to touch; pain due to a stimulus that does not normally provoke pain).

Large fibers, on the other hand, represent a smaller subset of peripheral nerves and, when dysfunctional, lead to negative symptoms, such as loss of proprioception and vibration sense, diminished ankle reflexes and numbness. Dr. Polydefkis points out that “large fibers also innervate muscles and, therefore, can be associated with weakness when injured.”

ad goes here:advert-2
ADVERTISEMENT
SCROLL TO CONTINUE

Most neuropathies, such as diabetic neuropathy, involve dysfunction of both small and large fibers. Dr. Polydefkis says “in many instances, small fibers are affected first, and patients then develop large fiber involvement with time,” as occurs in diabetes.

Length dependence is an essential concept to be cognizant of when evaluating for neuropathy. When a neuropathy presents in a length-dependent manner, it first appears in the nerves of the greatest length, such as at the toes, and then progresses proximally up the lower extremities, with eventual involvement of the hands and upper extremities. This is the classic pattern of a diabetic- or alcohol-related neuropathy. Small fiber neuropathy, however, can be non-length dependent,and proximal  regions may be affected first, with patchy involvement that does not map onto a particular sensory nerve distribution.2

Page: 1 2 3 4 | Single Page
Share: 

Filed under:ConditionsOther Rheumatic ConditionsSjögren’s DiseaseSystemic Lupus ErythematosusSystemic Sclerosis Tagged with:neuropathyPeripheral Neuropathysmall fiber neuropathy

Related Articles
    Right: The same view as 2A, with the common peroneal nerve outlined in yellow with a cross-sectional area of 21 mm2.

    Case Report: Ultrasound Reveals Cause of Post-Arthroplasty Knee Pain

    April 15, 2020

    A 65-year-old woman was referred by an orthopedist to a rheumatologist for left knee pain. Previously, in 2014, she underwent left total knee arthroplasty (TKA) for severe osteoarthritis in a different institution. Following the procedure, she experienced severe chronic anterolateral knee pain at rest, exacerbated by walking. Because she was rendered wheelchair bound and required…

    Using Ultrasound to Diagnose Carpal Tunnel Syndrome

    April 26, 2018

    Note: Updated May 2, 2018, to correct a link in the reference section. The error was introduced in editing. A 44-year-old Caucasian woman presented to the outpatient rheumatology clinic that had followed her for several years for rheumatoid arthritis. She was compliant with her regimen of hydroxychloroquine, etanercept and salsalate. Her chief complaint was worsening…

    A transverse view of the ulnar groove in full elbow extension. The red arrow indicates the advancing edge of the MHTr.

    Recurrent Medial Elbow Pain Following Successful Tommy John Surgery

    August 12, 2020

    A 27-year-old, left-handed man was referred to our ultrasound clinic for left elbow pain. History The patient had been a pitcher on a Minor League Baseball team. Two years before, he developed sudden, severe medial elbow pain while pitching in a game. The pain was associated with some tingling down the left medial forearm. The…

    EULAR 2013: Tips for Managing Peripheral Neuropathy in Rheumatic Disease

    September 1, 2013

    How to determine which tests to order, how to interpret them, and how to decide on the right treatment course

  • About Us
  • Meet the Editors
  • Issue Archives
  • Contribute
  • Advertise
  • Contact Us
  • Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 1931-3268 (print). ISSN 1931-3209 (online).
  • DEI Statement
  • Privacy Policy
  • Terms of Use
  • Cookie Preferences