Diabetic Peripheral Neuropathy: Causes, Symptoms, and Outlook

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Diabetic peripheral neuropathy is nerve damage caused by diabetes that occurs in the extremities—the feet, legs, hands, and arms. This is the most common type of neuropathy in people with diabetes and affects about one-third to one-half of people with diabetes.

The risk of developing diabetic peripheral neuropathy increases with the duration of diabetes. Other factors that may increase a person's risk include glycemic control (as measured by hemoglobin A1C), age, smoking, diabetic retinopathy, high triglycerides, height, and body mass index (BMI).

Symptoms of Diabetic Peripheral Neuropathy

Verywell / Michela Buttignol

Causes of Diabetic Peripheral Neuropathy

The exact cause of peripheral neuropathy is unclear. But we know that elevated blood glucose, metabolic factors, genetic predisposition, and duration of diabetes can increase the risk.

Elevated blood sugars and inadequate blood flow can result in nerve damage in the extremities. High blood glucose can impair the nerves' ability to transmit signals and cause chemical changes. Elevated sugar can also damage blood vessels that carry oxygen and nutrients to the nerves.

Nerve signaling in neuropathy is disrupted when there is a loss of signals normally sent, inappropriate signaling from nerves, or errors in nerve signaling that distort messages being sent.

When nerve damage to the extremities causes damage to multiple peripheral sensory and motor nerves, it is referred to as diabetic polyneuropathy. This can lead to loss of sensation, difficulty in wound healing, and an increased risk of infection.

Diabetic Peripheral Neuropathy Symptoms

Symptoms will vary depending on which nerves are affected. Small nerves protect your body by sending signals about pain and temperature changes to your brain; when these nerves are affected, you may experience hot and cold sensitivity and pain.

Diabetic neuropathy can also attack large nerves that detect touch and pressure and help you keep your balance.

Numbness and Loss of Protective Sensation (LOPS)

Numbness in the hands and feet is a type of sensory neuropathy and affects the large nerve fibers. People can also experience numbness in the legs and arms.

LOPS indicates the presence of distal sensorimotor polyneuropathy and is a risk factor for diabetic foot ulceration. When you have a loss of sensation in your feet, you are less likely to feel a foot injury. A foot injury that is undetected can become infected.

Burning and Tingling in Feet

Tingling or burning in the feet, also referred to as dysesthesia, occurs when the small nerve fibers are affected. This is the most common early symptom of neuropathy.

Shooting Pain and Painful Cramps

This type of neuropathy affects the motor nerves and is commonly associated with muscle weakness. Painful cramps that are felt in the legs, particularly when walking that cease when at rest, may need a further workup from a vascular surgeon. This doctor specializes in surgery to correct problems with blood flow.

This symptom, referred to as intermittent claudication, can be a symptom of peripheral vascular disease, in which an artery supplying the limb is partially blocked.

Loss of Balance

Peripheral nerve injury can affect balance in people with diabetes and can increase the risk of falls.

Appearance of Deformity in Foot

Underlying neuropathy and trauma to the foot can lead to deformities of the foot, including hammertoes, bunions, and Charcot foot.

Charcot foot affects the bones, joints, and soft tissues of the foot and ankle. Diabetic neuropathy is the most common underlying cause. Sensory, motor, or autonomic neuropathy, trauma, and metabolic abnormalities all contribute to Charcot foot.

Injuries to Foot You Can’t Feel or Explain

When people with diabetes have a loss of sensation in their feet, they may not feel it when they injure themselves. An injury that is left untreated can cause a bigger issue, such as an ulcer or infection. It's important to wear proper shoes and avoid walking around barefoot.

Hot and Cold Sensitivity

Nerve damage can interfere with the body's ability to feel temperature. An inability to feel or sense heat can increase the risk of burns. If you have neuropathy that affects your ability to sense heat, avoid stepping directly into a hot tub; use your forearm to check the water or another part of your body that has sensation.

Nerve damage can also reduce blood flow to the feet and hands, making them feel cold or get cold more quickly.

Pain Affects Sleep

Neuropathy that has gone undetected or has not been treated for many years can become severe. In this case, pain can occur during everyday activities such as walking and sleeping.

Diagnosing Diabetic Peripheral Neuropathy

The American Diabetes Association (ADA) states that, "Up to 50% of diabetic peripheral neuropathy may be asymptomatic. If not recognized and if preventive foot care is not implemented, patients are at risk for injuries to their insensate feet."

It's important for people with diabetes to have their feet examined during routine medical visits. Your healthcare professional or certified diabetes care and education specialist can do a foot exam to inspect your feet visually and determine your level of sensation. If an issue exists, further workup may be necessary.

Foot Exams

The ADA Standards of Care recommends, "Patients with type 1 diabetes for five or more years and all patients with type 2 diabetes should be assessed annually for diabetic peripheral neuropathy (DPN) using the medical history and simple clinical tests."

Detailed foot assessments may occur more frequently in people with histories of ulcers or amputations, foot deformities, insensate feet, and peripheral arterial disease (PAD). Clinical tests may be used to assess small- and large-fiber function and protective sensation:

  • Small-fiber function: Pinprick and temperature sensation
  • Large-fiber function: Vibration perception and 10-g monofilament or using a 128-Hz tuning fork
  • Protective sensation: 10-g monofilament
  • Inspection and palpation for pedal pulses

Nerve Conduction Studies and EMG

Nerve conduction studies (NCS) and electromyography (EMG) testing may be used to confirm the presence of peripheral neuropathy and assess its pattern and severity, prognosis, and possible treatment options. The ADA suggests that these types of tests are rarely needed except when the clinical features are atypical and the diagnosis is unclear.

Treatment

Treatment protocols should be developed based on a person's unique health history and symptoms. There is no specific treatment for underlying nerve damage, but glycemic control can help to prevent diabetic neuropathy in type 1 diabetes and may slow the progression in type 2 diabetes.

Medications and other nonpharmacologic strategies can help to reduce pain and increase quality of life.

Glycemic Control

For people who have blood sugars that are too high, optimizing blood sugar control can help to prevent and slow the progression of neuropathy.

Blood sugar management strategies may include finding the best medication options, encouraging medication adherence, and diabetes self-management education such as meal planning, exercise, and smoking cessation, to name a few.

Foot Care Education

Learning how to care for your feet is important in preventing and treating neuropathy. People with diabetes should understand how to do their own foot exams. To examine your feet, inspect between your toes and the bottoms of the feet (using an unbreakable mirror). Inspect your feet for dry, cracked skin.

After showering, dry your feet well, especially between the toes, and do not apply lotion between the toes. This area is very moist, and lotion can increase the risk of fungal infections. Avoid walking around barefoot. Wear clean, dry cotton socks.

Check your feet daily if you have a history of neuropathy or foot injury. If you find anything suspicious or out of the ordinary, be sure to contact your doctor.

Medications

Your doctor may talk to you about starting certain medications to reduce neuropathic pain. Lyrica (pregabalin), Cymbalta (duloxetine), or Neurontin (gabapentin) are recommended as initial pharmacologic treatments for neuropathic pain in diabetes.

Special Footwear

Therapeutic footwear is recommended for those at high risk who have severe neuropathy, foot deformities, ulcers, callus formation, poor peripheral circulation, or a history of amputation.

When to See a Doctor

Pain from neuropathy can impact quality of life and lead to feelings of sadness. If you are in pain, you should seek medical treatment. Certain medications can help to alleviate pain.

In addition, if you have a wound that won't heal, notice any deformities, or are experiencing muscle pain, weakness, or cramping, you should contact your doctor. Many people with diabetes benefit from seeing a podiatrist, who specializes in foot care.

Summary

Diabetic peripheral neuropathy is a very common type of neuropathy in people with diabetes. Screening, early detection, and treatment can help prevent and slow down the progression of the disease.

The earliest symptoms include numbness and tingling and may appear gradually. All people with diabetes need to have their feet inspected by a medical professional. In addition, understanding what to look for and how to inspect your own feet is important.

A Word From Verywell 

Diabetic peripheral neuropathy can be difficult and painful, but know that you are not alone. Reach out to your medical team to receive education and treatment based on your own personal symptoms.

Early detection and treatment can prevent further progression and reduce the risk of complication and pain. Make sure your medical team is examining your feet at your appointments.

Frequently Asked Questions

  • What is the difference between diabetic neuropathy and peripheral neuropathy?

    Diabetic neuropathy is a general term that includes all forms of neuropathy in people with diabetes. This can include peripheral neuropathy and autonomic neuropathies, such as cardiac neuropathy, gastroparesis, urinary and sexual neuropathies, etc. Peripheral neuropathy generally affects the nerves in the feet, legs, hands, and arms.

  • Is peripheral neuropathy reversible in a person with diabetes?

    Early detection and treatment may prevent neuropathy (especially in type 1 diabetes) and stop or slow the progression in type 2 diabetes. But nerve function that is lost usually cannot be restored. However, if a person with diabetes has an underlying condition that is causing the neuropathy, such as vitamin B12 deficiency, treating that underlying condition can reverse the neuropathy. The American Diabetes Association recommends that all people with DPN be checked for other causes of neuropathy, such as exposure to toxins, renal disease, hypothyroidism, vitamin deficiencies, infections, malignancies, inherited neuropathies, and vasculitis.

  • Does diabetic neuropathy go away?

    If the underlying cause of the neuropathy is elevated blood sugars, then getting blood sugars under control may improve certain symptoms. Unfortunately, by the time many people get diagnosed, there may be some degree of permanent damage.

  • What can be mistaken for neuropathy?

    Neuropathy can have many causes. Sometimes people with cardiovascular disease and diabetes may also have peripheral artery disease, which can cause similar feelings of numbness, tingling, and cramping in the legs and feet.


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