--even many neurologists, are not all that familiar with small-fiber neuropathy. In fact, many will tell you that if your nerve conduction studies and EMG are normal, you don't have neuropathy at all. But nerve conduction studies and EMG's can only measure gross abnormalities of larger, myelinated nerve tracts; they are simply too gross a measure to find small-fiber damage. THAT can be documented through specialized testing--qualitative sensory testing, autonomic testing, or the current gold standard--skin biopsy to measure the density and condition of intraepidermal fibers.

It's annoying that this still goes on, as small-fiber syndromes are the most common presentation of diabetic nerve damage, as researchers such as Aaron Vinik have documented through many, many studies. It is thought that is such cases the nerve damage is primarily caused by ischemic compromise (circulatory breakdown) rather than direct nerve assault; glucose dysregulation leads to inefficiency of small blood vessels, which cannot bring nutrients/oxygen to the nerves and cannot carry away toxic metabolic by-products, so that the nerves starve and get poisoned over time. This is why anything that helps diabetics improve circulation (especially exercise) is important in combating the spread of the neuropathy. Tight blood sugar control is also necessary.