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Neuropathy is the loss of sensation, and it is the number one disease that affects the diabetic that leads to loss of limb.



What is Peripheral Neuropathy?

Peripheral neuropathy involves damage to the peripheral nervous system, and there are multiple different types. Diabetic neuropathy is one of those types, and similar to other causes of peripheral neuropathy may lead to severe burning pain along with pins and needles in the feet and legs.

There are two regions to the nervous system — Central and Peripheral. The Central system includes the brain and spinal cord, while the Peripheral system includes all the nerve roots and extremity nerves emanating from it. Examples of peripheral nerves include lumbar nerve roots, the median nerve, the shoulder's brachial plexus, the sciatic nerve, etc. It's a broad network, and all of these peripheral nerves transmit vital motor and sensory information throughout the body. They may tell your foot when to feel cold, or cause pain in your shoulder, or allow your biceps to flex. A peripheral neuropathy may interrupt some of these transmissions, or at a minimum distort them.

Symptoms from peripheral neuropathy emanate from this damage. Some individuals with peripheral neuropathy experience tingling, numbness, or pricking sensations, sensitivity to touch, or muscle weakness. More severe neuropathy symptoms may include burning pain, muscle wasting, paralysis, or gland dysfunction.

Neuropathy is usually characterized by phases:

  • Phase I of neuropathy is a tingling sensation in the plantar aspect (bottom) of the foot that may manifest as a feeling of bugs crawling or bees stinging, and this term is referred to as formication. This is a very important indicator that loss of sensation is happening.
  • Phase II has the symptoms that come more frequently and are more intense.
  • Phase III is characterized by a constant burning of the feet that causes disruptions in sleep. This phase usually requires medication such as pain pills or other medications such as Neurontin.
  • Phase IV is characterized by moments of relief. The patient is falsely convinced that their disease is improving because there are moments of lack of pain; but really what is happening is that the condition is progressing into Phase V, which is not total relief of pain but complete loss of sensation. This is the most dangerous phase and this is when ulcers develop.

Types of Peripheral Neuropathy

There are 3 types of peripheral neuropathy:

  1. Mononeuropathies = damage to only one nerve
  2. Polyneuropathy = multiple nerves affecting all limbs
  3. Mononeuritis multiplex = 2 or more nerves in separate areas of the body being affected in isolation.

Peripheral neuropathy is complicated in how it progresses, resolves, or plateaus. Diabetic neuropathy, which is a polyneuropathy, often affects one's feet first, travels up both legs, and then subsequently affects the fingers and hands moving up the arms. It is ascending nerve damage. Not everyone experiences the same pain areas or severity.

An example of a mononeuropathy is carpal tunnel syndrome, where the median nerve is a victim of compression in a person's wrist. It is where one nerve is affected, and it is well known that there are infinite levels of severity with a mononeuropathy. It may affect a person so severely that surgery becomes necessary, or it may simply be a nuisance from time to time.

Mononeuritis multiplex is a fairly complicated, painful condition involving at least 2 separate nerve areas. It is actually a group of disorders that is associated with disorders such as diabetes, rheumatoid arthritis, vasculitis, amyloidosis, Lyme disease, and potentially numerous other conditions. The incidence of mononeuritis multiplex in the US is actually unknown.

What causes peripheral neuropathy?

The most common cause of peripheral neuropathy is diabetes (by far). Sometimes the cause is completely unknown (idiopathic). Here are some other potential causes for neuropathy:

  • Autoimmune disorders rheumatoid arthritis or lupus
  • Chronic kidney disease
  • Infections such as HIV and liver infections
  • Low levels of vitamin B12 or other problems with your diet
  • Poor blood flow to the legs
  • Underactive thyroid gland
  • Drug use such as heavy alcohol consumption
  • Toxin exposure such as lead, mercury, and solvents may lead to peripheral neuropathy.
  • Pharmaceutical drugs used to treat infections, cancer, seizures, or high blood pressure.

What are the symptoms of peripheral neuropathy?

Peripheral Neuropathy

Symptoms will vary based on which nerve(s) is damaged. One of the most disturbing symptoms of neuropathy is "deep" pain. This typically affects the feet first, travels up the legs somewhat, and then begins in the fingers and hands. An early sign of neuropathy may be tingling or burning in either the arms or legs, which along with the pain often start in the feet and legs.

As the neuropathy progresses, patients may actually start to lose sensation in the feet. This becomes problematic when patients try to walk, and cannot properly feel their feet under their body. Also, patients lose the ability to notice hot from cold on their feet, or not notice a blister or sore on the foot which can exacerbate readily.

Along with sensory problems, peripheral neuropathy may unfortunately cause muscle weakness. Patients may trip more often, legs may buckle, and a cane or walker may become necessary. Manual dexterity tasks such as buttoning shirts or handwriting may become difficult.

Organs may be affected by peripheral neuropathy as well. The heart may not provide warning pain (angina) of a heart attack due to neuropathy, leading to a "hidden" attack. Patients may experience digestive problems, stool inconsistencies, or swallowing issues.

Men may experience erectile dysfunction, and women may experience vaginal dryness. Both sexes may experience bladder problems with leaking or difficulty emptying.

Testing and Diagnosis

Every workup for peripheral neuropathy initially consists of a careful medical history and comprehensive physical examination. Depending on what is found during this workup, patients then may need varying studies.

Typically a set of laboratory studies is performed to establish electrolyte levels and look for disease markers. X-rays can show the extent of arthritis and rule out problems with bony areas. An MRI may be necessary to see if there is a source of nerve compression, such as a tumor or herniated disc.

The Pressure Specified Sensory Device (PSSD)

The Pressure Specified Sensory Device (PSSD) is the most accurate way of testing the lower extremity for sensory deficits. The PSSD is one of the best sensory measuring devices available that can quantify and record both specific peripheral nerve threshold levels and peripheral never innervation density (which reflects axonal degeneration). The PSSD is able to quantify pathologic changes at subclinical levels and is pain free.


Nerve Conduction Velocity Equipment

Nerve conduction velocity equipment is particularly useful in differentiating between lower back pathology, radiculopathy and distal motor/sensory neuropathies. This can tell which nerves are involved and the severity of the neuropathy.

This device has a specificity of 90% and sensitivity of 86%. It is well tolerated by patients and is comparable to the traditional NCV/EMG testing.


A muscle biopsy may be necessary, and often a gait analysis can show how abnormal a person's walking truly is. With proper treatment, the gait may correct substantially.

The exact combination of studies necessary will be ordered depending on what the doctor needs to establish the diagnosis and severity and decide on treatment options.

What kind of treatments exist for peripheral neuropathy?

  • Medications
    • Pain Medications — Opioids like Morphine may help substantially, or not at all. There are also non-narcotic pain medications such as Ultram which may provide relief.
    • Neurologic Modifying Agents — These include medications such as Lyrica, or Neurontin. They can help modulate the burning sensations from the neuropathy.
    • NSAIDS, Tylenol — Over the counter and inexpensive, these may help substantially for mild to moderate pain.
    • Antidepressants — They help with depression, but outside of that have shown success in modulating neuropathic pain. There are several different types, such as Tricyclic Antidepressants or Serotonin Reuptake Inhibitors.
    • Future agents — As more research is performed regarding proteins and factors causing peripheral neuropathy, more medications will become available to combat the progression and/or formation of the problem.
  • Surgery
    • Certain types of peripheral neuropathy are amenable to a surgical solution.
    • For diabetic neuropathy and other types of polyneuropathy, the Dellon Procedure may assist substantially with alleviating pain and stopping the disease progression.
    • Depending on the cause of other types of neuropathy, other types of surgery may cure the problem.  For instance, if the problem is a mononeuropathy with tarsal tunnel syndrome, then releasing the nerve should most likely make the pain go away.
  • Soft Tissue Laser
  • Laser
    • Laser therapy uses specific wavelengths of light that have a strong anti-inflammatory effect on tissues and helps decrease the pain from peripheral neuropathy. Laser therapy is FDA cleared, painless, and immediately improves local blood circulation.
  • Injections
    • If the neuropathy is amenable to a focal injection, steroid medication plus a numbing agent may work wonders for pain relief.
    • In addition, there is a new injection material available that is stem cell rich and also includes anti-inflammatory agents and proteins that may assist in reducing the pain of peripheral neuropathy substantially.

Dellon Compression for Nerves

At the Foot Pain and Vein Centers we use the Dellon Decompression, named after Dr. Lee Dellon, professor of neurosurgery andplastic surgery at John Hopkins University Medical School. Dr. Jacoby was personally trained by Dr. Dellon on this procedure. The procedure relieves pressure on the nerve by making the tunnel the nerve travels through, wider. The Neurogenix procedure is a non-surgical approach as well. Find out more about The Dellon Treatment.

What should I expect with treatment results?

If the cause of the neuropathy can be established and it is treatable, the symptoms may be substantially improved. Such as with diabetes, patients may be able to get their blood sugars under control.

If a patient is an alcoholic and that's causing neuropathy, it should be ceased. If the blood tests show some vitamin or electrolyte abnormalities, replenishment may assist with the symptoms.

If surgery is indicated, the results will vary depending on the operation being performed along with how long the condition has been present.

Physical Therapy may help improve muscle weakness a lot, and the injections may decrease pain for months on end.

There are so many variations to peripheral neuropathy, it is too difficult to make broad sweeping treatment result statements.

Related Links:

Neuro-Eze Neuropathy Cream

Eases neuropathic pain, increases circulation

Neuropathy Statistics

Sixty to 70 percent of diabetics have mild to severe forms of nervous system damage. This translates into impaired sensation in hands and feet, slowed digestion in the stomach and carpal tunnel syndrome. Thirty to 40 percent of diabetics over age 40, have impaired sensation in their feet.

Signs of Diabetic Nerve Pain

  • Tingling in toes and ankles
  • Burning in the feet that worsens at night
  • Pain when standing
  • Pain when wearing shoes


  • More than 60 percent of nontraumatic lower limb amputations are due to diabetic neuropathy.
  • One in six diabetics will have ulcers of the lower extremity.
  • One in six diabetics will who have ulcerations will have amputations.

What Is Metabolic Syndrome X?

In 1988, Stanford endocrinologist Gerald Reavan, M.D., came up with the phrase Syndrome X, or Metabolic Syndrome X. This is a condition brought about by excessive refined carbohydrate diets. In order to have Metabolic Syndrome X, a patient must present with at least two of the following; insulin resistance, elevated cholesterol or triglycerides, abdominal obesity and high blood pressure. Having Metabolic Syndrom X increases the likelihood of becoming diabetic and having cardiac problems.

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