Peripheral neuropathy evaluation

What is peripheral neuropathy?

Peripheral nerves carry sensation, control muscles and regulate functions such as sweating. In peripheral neuropathy, many of these nerves are damaged. Because the longest nerves are usually affected first, symptoms typically begin in the toes and feet and may later involve the hands — a pattern sometimes described as “stocking and glove.”^[1,2]

Symptoms

• numbness, reduced feeling or a “wooden” or “cotton wool” sensation in the feet
• tingling, pins and needles, or burning, often worse at night
• sharp, stabbing or electric pains
• extreme sensitivity to touch
• poor balance or unsteadiness, especially in the dark
• weakness, or changes in foot shape over time
• dry, cracked skin or changes in sweating^[5]

Some people have little pain but significant loss of feeling — and loss of protective sensation is what puts feet at risk of unnoticed injury.^[3]

Common causes

• Diabetes — the most common cause in the United States.^[3]
• vitamin deficiencies, especially vitamin B12
• heavy alcohol use
• certain medications, including some chemotherapy drugs
• kidney disease, thyroid disease and autoimmune conditions
• infections and inherited conditions
• in some people, no cause is found despite thorough testing^[1]

Our role in neuropathy care: a foot-focused evaluation

A foot-focused evaluation complements the care you receive from your primary care physician, endocrinologist or neurologist. It typically includes:

• a detailed history of your symptoms, health conditions and medications
• a foot examination: sensation testing with a monofilament and vibration, reflexes, circulation, skin and nails, foot shape and pressure points, and your footwear^[4]
• an assessment of your risk of ulcers and injury, with a plan for protective care and follow-up
• a check for problems that can coexist with neuropathy, such as a focal nerve entrapment like tarsal tunnel syndrome, which is evaluated on its own merits

Finding the cause of neuropathy usually involves blood tests and sometimes nerve-conduction studies and EMG. These are typically arranged with your primary care physician or a neurologist, and we coordinate with them.^[6]

Neuropathy vs. a pinched nerve

Peripheral neuropathy usually affects many nerves, often in both feet, and commonly has a body-wide cause. A nerve entrapment is a problem at one point along a single nerve and typically causes symptoms in that nerve’s area. The two can overlap, and people with neuropathy may be more vulnerable to entrapment. Telling them apart matters because the treatments are different. Learn more about nerve entrapment in the foot and ankle.

Treatment and management

• Treat the cause where possible — for example, improving blood-sugar control, correcting vitamin deficiencies or adjusting medications, with your other clinicians.^[1]
• Manage nerve pain. Several oral and topical medications can reduce neuropathic pain. They are usually prescribed and adjusted by your primary care physician, endocrinologist, neurologist or pain specialist.^[4]
• Protect your feet. Appropriate footwear, orthotics where needed, care of calluses and nails, and prompt treatment of any wound (external site).^[7]
• Balance and strength. Physical therapy can help with steadiness and reduce the risk of falls.

About nerve decompression surgery for neuropathy

You may see nerve decompression surgery promoted as a treatment for diabetic neuropathy. The American Academy of Neurology has described it as unproven, and a Cochrane review found no well-designed trials showing that it improves symptoms in symmetrical diabetic neuropathy.^[8,9] This is different from treating a specific, well-documented nerve entrapment, which is assessed individually.

Daily foot care with neuropathy

When to seek care

Make an appointment if you have new or worsening numbness, tingling or burning in your feet, if you have diabetes and haven’t had a foot examination in the past year, or if you notice changes in the shape of your feet.