Cold feet or numb feet? Circulation versus nerves

“My feet feel numb and cold” could mean two quite different things. The nerves that carry sensation could be damaged, or blood isn’t getting to the feet as well as it should, or both. Telling them apart matters, because the treatments are completely different and one of them can be urgent.

What each one tends to feel like

Nerve problems tend to cause numbness, tingling, pins and needles, burning, or shooting pain. In peripheral neuropathy, symptoms typically start in the toes and creep upward, on both sides.^[3] A pinched nerve usually affects a particular area of one foot.

Circulation problems in the legs are called peripheral artery disease. Its hallmark is intermittent claudication, which is cramping or pain in the legs with walking that eases with rest. But only about 10% of people with peripheral artery disease experience classic claudication. Another 50% have a variety of different leg symptoms, and about 40% have no leg symptoms at all.^[2] So a foot that doesn’t hurt is not proof that circulation is fine. Cold, pale or bluish toes or a sore that won’t heal also call for a circulation evaluation.^[1]

Who is at risk for circulation problems

The most significant risk factors for peripheral artery disease are high cholesterol, high blood pressure, diabetes, chronic kidney disease and smoking, and having three or more of them is linked to a 10-fold increase in risk.^[2] Diabetes is also the most common cause of neuropathy, which is why the two problems so often appear together in the same person.^[3]

How doctors tell them apart

An evaluation looks at both systems:

• Nerves: feeling with a fine filament and vibration, strength, reflexes, tapping along the nerves that commonly cause trouble, and the back, hip and knee.
• Circulation: pulses, and skin color and temperature. Current guidelines recommend a resting ankle-brachial index test, which compares blood pressure in the ankle with the arm, for people whose history or examination suggests peripheral artery disease. People with symptoms but a normal resting result can be evaluated further with an exercise test.^[2]

If a circulation problem is suspected, it is managed with your primary care physician and, when needed, a vascular specialist. Treatment of peripheral artery disease includes lifestyle changes such as stopping smoking and supervised exercise, along with medicines, and surgical revascularization for some people. People with acute or limb-threatening ischemia should be referred immediately to a vascular surgeon.^[2]

When nerves and circulation overlap

Both can be present. A numb foot is easy to injure, and a foot with poor blood flow heals slowly. That combination is why a small unnoticed blister can turn into a serious wound, and why people with diabetes are asked to look at their feet every day and to have a foot examination at least once a year.^[4] See diabetic neuropathy: when to see a nerve specialist.

A foot-focused evaluation checks for nerve entrapments and neuropathy, and a circulation problem needs its own workup, which we coordinate with your other clinicians. You can read more in numb toes and numb toes: when to worry.

When to see a specialist

Make an appointment if your feet are numb, tingling or burning, feel cold, change color, or hurt when you walk and ease with rest. If you have diabetes, have any new foot symptoms checked promptly.