Diabetic Peripheral Neuropathy: Causes and Treatments

Diabetic Peripheral Neuropathy: Causes and Treatments

Testing blook sugar

Diabetes — a condition that affects more than one in 10 Americans — often leads to additional health problems called complications. One of the most common diabetes complications is peripheral neuropathy. People with this condition have nerve damage that leads to pain, tingling, numbness, or weakness in the hands and feet. About one in two people with diabetes have peripheral neuropathy.

What Causes Neuropathy?

Neuropathy is a disease of the nerves. The body uses nerves to communicate with the rest of the body. Some nerves send signals from the brain to other tissues, and then other nerves send signals back to the brain. This process helps the brain learn about feelings and sensations, tell muscles when and how to move, and control different processes in the body such as breathing and the heartbeat.

In people with diabetes, the body has a hard time controlling levels of sugar and fat in the blood. High blood sugar levels and high fat levels can directly damage the nerves and also harm the blood vessels that keep the nerves healthy. In people with neuropathy, the brain has a harder time receiving information from and sending signals to certain parts of the body.

Neuropathy can also be caused by other conditions. Certain genetic disorders that are passed down within families can lead to nerve damage. Other disorders such as Guillain-Barre syndrome, inflammatory conditions, or cancer may also lead to neuropathy. Environmental or lifestyle-related causes of neuropathy can include heavy drinking, not getting enough of certain vitamins or minerals, exposure to toxic substances, or infections.

Types of Neuropathy

Damage to different types of nerves can lead to different forms of neuropathy. These include:

  • Peripheral neuropathy: damage to the nerves in the feet or hands
  • Autonomic neuropathy: damage to the nerves that control body functions like digestion, blood pressure, sweating, vision, urination, and body temperature
  • Focal neuropathies: problems with a single nerve in the wrist, leg, head, or other location; includes carpal tunnel syndrome and eye problems
  • Proximal neuropathy: damage that affects nerves in the thigh, hip, or buttock, usually just on one side of the body

People with diabetes can develop any of these neuropathies. Peripheral neuropathy is the most common type of nerve damage.

Peripheral Neuropathy Symptoms

man holding arm
Peripheral neuropathy symptoms affect the feet, ankles, lower legs, hands, or arms. People with this condition may feel pain, burning, weakness, numbness, or “pins and needles” sensations. The sense of touch may also be affected in these areas. For example, people with peripheral neuropathy may not notice right away when their hand is touching something hot, or they may not realize that their shoes are too tight.

These symptoms can develop and worsen slowly over time, or they can appear quickly. They may be more severe at night than they are during the day.

Long-Term Effects of Peripheral Neuropathy

Over time, people with diabetic peripheral neuropathy may experience worsening problems with their feet. When it is harder for the nerves in the feet to pick up on different sensations, a person may be less likely to notice pain or discomfort. Some people with diabetes develop sores, blisters, or infections on their feet, and may not notice these issues right away.

Diabetes interferes with the body’s healing processes by preventing enough blood from flowing to injured tissues. This means that it is harder for the body to repair even minor injuries. Some people with diabetes who develop severe foot problems may need to have a toe or foot amputated.

When feet and leg problems pile up, it may become harder to walk. Some of those with neuropathy may have a hard time balancing properly. This can lead to falls, which puts a person at risk for breaking bones. A person’s sense of movement may also be affected. Peripheral neuropathy may also cause a lot of pain, especially while walking.

Diabetics with peripheral neuropathy are likely to need more frequent visits to their doctor’s office or the hospital. They may also have a hard time working because of pain or difficulties getting around. All of these issues can in turn lead to mental health disorders such as anxiety or depression.

Diagnosing Peripheral Neuropathy

woman holding lower back
If you are experiencing signs of peripheral neuropathy, talk to your doctor. You will likely need to have a physical exam. Your doctor will ask about your symptoms and your family and personal health history.

Blood tests are often a part of physical exams. These tests can identify various health problems that can cause neuropathy or be found in people with diabetes. Blood tests may be used to detect:

  • Abnormal blood cell levels
  • Thyroid disorders
  • Kidney or liver problems
  • Low levels of certain vitamins or minerals

During the physical exam, your doctor may perform several tests to see whether you are able to detect sensations with the nerves in your feet. One possible test is a monofilament test, in which the doctor touches your feet with a thin strand of nylon to see if you can feel it. Another test involves touching the feet with a tuning fork to see if the nerves in your feet can sense vibrations.

Doctors can directly measure how well your nerves and muscles are working with other tests. They may use nerve conduction velocity tests (NCV) to see how fast your nerves are able to send out signals. An electromyogram (EMG) measures electricity in the muscles, which helps doctors understand how fast your muscles respond to signals from the nerves.

Other tests may include checking your balance, seeing how well you walk, or testing the blood flow in your feet and toes.

Can Peripheral Neuropathy Be Prevented?

pricking finger

One of the most important ways people can reduce their risk of neuropathy is by treating their diabetes. Keeping blood sugar levels under control helps prevent the nerves from becoming damaged. Work with your doctor to develop a diabetes treatment plan that works for you.

Certain risk factors can increase a person’s chances of developing diabetic peripheral neuropathy. These include:

  • Being older
  • Having diabetes for a long period of time
  • Having certain genes
  • Smoking cigarettes
  • Heavy drinking
  • Being overweight
  • Having other health problems such as high cholesterol levels or hypertension (high blood pressure)
  • Being diagnosed with other conditions, including kidney disease

You can’t control some peripheral neuropathy risk factors like age or genetics. However, you can reduce your risk of nerve damage by focusing on certain lifestyle changes. Getting more exercise, eating a balanced diet (especially superfoods for diabetics), quitting smoking, and limiting how much you drink may help you avoid peripheral neuropathy. Additionally, use lifestyle changes or medication to prevent or treat high blood pressure or cholesterol levels.

Peripheral Neuropathy Treatments

If you are suffering from neuropathy pain, the first step is talking to your doctor, who can help you come up with a treatment plan. Make sure to ask about ways to both treat the neuropathy as well as keep your diabetes under control to prevent further damage.

Medications for Peripheral Neuropathy

Several different types of drugs can help manage peripheral neuropathy pain. However, traditional painkillers may not always be the best option. In particular, over-the-counter pain medications often do not work for neuropathic pain. These include non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen as well as other drugs like acetaminophen.

Instead of utilizing traditional pain relievers, physicians sometimes recommend a medication for nerve pain that is in the “antidepressant” category of medicine because of the mechanism of action of this medication. These medications don’t heal nerve damage, but they can reduce neuropathy symptoms. Possible options may include:

  • Pamelor (nortriptyline)
  • Norpramin (desipramine)
  • Tofranil (imipramine)
  • Elavil (amitriptyline)
  • Cymbalta (duloxetine)
  • Effexor (venlafaxine)
  • Paxil (paroxetine)
  • Celexa (citalopram)

Anti-seizure medications may be another option for treating peripheral neuropathy pain. These drugs may include Neurontin (gabapentin) or Lyrica (pregabalin). Finally, topical medications that are applied directly to the skin may help. Your doctor may be able to prescribe a cream, spray, or patch that can numb pain.

These medications are not always equally effective for everyone. If you try one medication and it doesn’t seem to be helping, notify your doctor — another drug may work better for you.

When blood sugar levels rise, some of these medications may not work as well to treat neuropathy symptoms. Following your diabetes treatment plan is important when trying to treat nerve pain and treating the root cause of the problem is the goal in working to reduce neuropathy and neuropathic pain.

Supplements for Neuropathy

Several studies have found that alpha-lipoic acid can work well to treat neuropathy symptoms. This molecule is an antioxidant that is made by the body. Alpha-lipoic acid treatments are especially effective when they are given intravenously, through an IV needle that goes directly into a vein.

This antioxidant is also available as an over-the-counter supplement. In this form, alpha-lipoic acid may still help with symptoms, but it is not usually as effective as IV treatments.

Physical Therapy

People with diabetic neuropathy may want to consider going to physical therapy (PT). This type of treatment can help you build strength and improve your balance. During PT, you will work with a physical therapist to perform different exercises that specifically address your needs.

Caring For Your Feet


Taking good care of your feet can help prevent minor problems from getting worse. Doctors recommend that people with peripheral neuropathy check their feet every day. If you notice a small issue right away and seek treatment, you have a better chance of healing and avoiding infection. Try looking for:

  • Cuts, sores, or areas where the skin is broken
  • Blisters
  • Calluses (areas of thicker skin)
  • Plantar warts (a hard, rough growth on the surface of the skin)
  • Rashes such as athlete’s foot
  • Ingrown toenails (a condition in which the edge of a toenail grows into the flesh, or the surrounding skin starts growing over the nail)

Try to get into the habit of washing your feet each day. Make sure the water that you use isn’t too hot. If you have a hard time sensing temperature, use a thermometer to measure the water before washing. Don’t use water above 95 degrees Fahrenheit (35 degrees Celsius). Once you are done, dry your feet thoroughly. Dust your feet with baby powder or cornstarch to help keep your skin dry.

Another way to protect your feet is always wearing socks and shoes. Socks can help keep your feet dry, while shoes protect your feet from injury. Make sure your shoes aren’t too tight, and break in new shoes by wearing them for short periods of time when you first get them. Before putting on your shoes, check that there are no small stones or other objects inside that could hurt your feet.

Certain types of footwear can also help prevent ulcers. Ask your doctor about whether insoles, shoes, or orthotics may help support your feet.

yearly foot exam is also a good idea for people with peripheral neuropathy. During this visit, your doctor can make sure your feet are in good health. More frequent exams may be needed for people who have current or past foot problems. You may be able to go to your primary care provider for this exam, or your doctor may recommend that you see a podiatrist (a doctor who specializes in treating feet).

Controlling Diabetes

Managing your blood sugar levels is a very important part of treating and controlling nerve damage. Make sure to check your blood sugar regularly. Choose nutritious foods that won’t lead to large blood sugar spikes, and get regular physical activity. Additionally, use any medications as directed by your doctor.

If you don’t think that you are controlling your blood sugar levels well enough, talk to your health care team. Your doctor may be able to help you better understand which treatments or lifestyle changes will help prevent complications from diabetes. A certified nutritionist or registered dietician can also help you come up with a better eating plan.


It is important to take peripheral neuropathy seriously, since symptoms can get worse and may cause additional problems over time. Effectively treating your diabetes can help you avoid nerve damage or prevent existing symptoms from worsening. Medications can help relieve symptoms of peripheral neuropathy, including pain. Follow the directions of your health care team when it comes to making necessary lifestyle changes and taking care of your feet. If you are having nerve pain and would like to discuss it further, please make an appointment. 

Pinched Nerve / Impingement

Pinched Nerve / Impingement

Pinched Nerve Sign

Pinched Nerve/Impingement

A pinched nerve is a common complaint in people seeking medical care. Also known as nerve impingement, a pinched nerve can occur at nerve roots coming from the spine, or in other areas like the wrist and ankle. In either case, it often results in pain and/or numbness and tingling in an arm or leg. Luckily, symptoms are usually treatable with conservative care and don’t require surgery. It’s important to know what to look for, however, because the symptoms aren’t always what you might expect.

What is a Pinched Nerve?

A pinched nerve, or nerve impingement, goes by different names when occurring in different areas of the body. When a nerve root is compressed at the spine, it’s called radiculopathy and is usually caused by degenerating bone or disc. When a nerve is impinged in the arm or leg, it’s called entrapment or compression. To better understand how nerve impingement affects the body, let’s examine the function of nerves.

How Do Nerves Work?

Nerves are our master communicators. They take information from the brain and send it to the rest of the body, and vice versa. The ultimate goal is to maintain a state of balance in the body called homeostasis. Nerves communicate in various ways, triggering sensory and motor reactions to protect the body. For instance, when you touch a hot stove, the nerves in your skin send signals to your brain at lightning speed that danger is present. Your brain responds by sending a burning pain to sensory nerves in your hand, while simultaneously sending a message to your motor nerves to pull your hand away. Nerves, in a nutshell, keep us alive and well. Unfortunately, they are the primary source of pain, too. Peripheral nerves, or nerves that connect our brain to our body, originate as nerve roots exiting the vertebrae from the spinal cord. From here, they branch out and supply, or innervate, muscles to help us move, sensory areas to help us feel, and autonomic areas to activate our fight-or-flight and rest-and-digest responses. When something puts pressure on a nerve root, it affects everything the nerve branches out into. Compression of a nerve root can cause weakness, numbness, tingling, and dull, nagging pain. Irritation of a nerve root can cause sharp, shooting pain, burning, and hypersensitivity.

Types of Nerve Impingement

Nerve root impingement at the spine (radiculopathy), can occur at any of the 3 main spinal sections: cervical, thoracic, and lumbar. Nerve roots in the neck, or cervical spine, primarily affect the arms (upper extremities). Nerve roots in the midback, or thoracic spine, affect the trunk and ribcage. Nerve roots in the low back, or lumbar spine, affect the low back and legs (lower extremities). Pinched nerves can also occur in other areas of the body. Think about when you wear tight shoes to a wedding and feel a tingly sensation in your feet by the time dinner is served. You end up kicking your shoes off to dance after dinner because a nerve in your foot was being compressed. Common areas of nerve entrapment are the carpal tunnel at the wrist and tarsal tunnel in the ankle.

Cervical Impingement

man touching sore shoulder
Nerve impingement in the neck is most common among adults ages 50-54 and is often mistaken for a shoulder or arm injury. Many times, the person feels arm pain or numbness but never has any neck pain. A basic understanding of cervical impingement can help direct proper treatment.

How Does it Happen?

A pinched nerve in the neck, or cervical radiculopathy, occurs when a nerve root is compressed by herniated disc material, a degenerating disc, or aging bone. The body activates the inflammatory response, which causes swelling around the nerve root. This ultimately leads to pain and changes in nerve function.

While internal changes in the neck are the culprit for a pinched nerve, there are often external events that trigger the symptoms to follow. These inciting factors can contribute to the onset of pain with cervical radiculopathy:

  • Poor posture
  • Trauma (such as car accident)
  • Sleeping in uncomfortable positions

What are the Symptoms?

A person with cervical radiculopathy may have symptoms in one or both arms and feel pain and/or numbness and tingling. Symptoms may go all the way into the fingers and follow a dermatome, or sensory nerve root pattern. Neck movements may be painful, the affected arm might feel weak, and the muscles around the neck may be tight. A clinician will likely do in-office testing to rule in the diagnosis, but unless trauma has occurred, further testing is not usually needed. If conservative treatment fails, an X-Ray or MRI may be considered.

How is it Treated?

Most cases of cervical radiculopathy resolve with conservative (nonoperative) management. In fact, in a five year follow up study of patients who had conservative treatment, 90% of patients were symptom-free or only had mild symptoms. Conservative treatment starts with medication, which can include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxers, opioids for acute pain, and antidepressants for chronic pain. Physical therapy may be prescribed to stretch the neck muscles and strengthen the postural muscles. The physical therapist may also use manual therapy or spinal manipulation to help reduce muscle tightness, joint stiffness and pain. Mechanical traction may be used, where the neck is intermittently placed in decompressive positions. If symptoms persist, an epidural injection may be considered. Only if all these fail is surgery considered. The most common procedure for relieving a pinched nerve is an anterior cervical diskectomy and fusion.

Thoracic Impingement

woman holding lower back
Nerve impingement in the thoracic spine, where the ribs attach, is much less common than in the neck or low back, at least according to reports. It can get missed for months, or even years, however, since it mimics many other potentially life-threatening diseases. Thus, skilled evaluation is imperative with diagnosing thoracic radiculopathy.

How Does it Happen?

Thoracic radiculopathy, or nerve impingement in the thoracic spine, can be caused by degenerative disc disease, rib dysfunction, diabetes mellitus, and placement of spinal cord stimulator. Since it is more rare in the thoracic spine than in the cervical and lumbar spine, thoracic radiculopathy can get overlooked among clinicians. In addition, symptoms of thoracic radiculopathy can mimic heart attack, lung problems, cancer, or other visceral organ dysfunction, making it important for doctors to rule out those conditions first.

What are the Symptoms?

People usually report radiating pain around the ribcage and in the trunk region. Pain may be present in the back near the shoulder blade (scapula) or in the lower abdominal region. Numbness and tingling may also occur, and it can feel painful to take a deep breath.


Like nerve impingement in the neck, thoracic radiculopathy typically resolves with conservative management; medications to reduce pain and inflammation, physical therapy to stretch muscles and correct postural imbalances, and activity modification are the first lines of defense. If these methods don’t improve a person’s symptoms, then a procedure called percutaneous vertebroplasty may be considered. In cases of progressive symptoms and neurologic compromise, surgery is necessary.

Lumbar Impingement

It goes by many names—sciatica, lumbar radiculopathy, lumbosacral radiculitis, radicular pain, and pinched nerve, to name a few. This literal “pain in the rear” can be a nuisance, and in some cases debilitating. Spinal nerves are tricky, and a pinched nerve in your back may feel like pain in your foot. Let’s examine why this happens.

How Does it Happen?

Dysfunction of a spinal nerve root in the lumbar spine (low back) is the cause of lumbar radiculopathy. When one is compressed or irritated, a person will develop symptoms of a pinched nerve. Depending on the severity of the compression, the nerve may be affected along its entire course through the body, which is sometimes down to the feet. Here are some common causes of lumbar radiculopathy:

  • Bulging disc
  • Herniated disc
  • Lumbar facet overgrowth (hypertrophy)
  • Spondylolisthesis

People can develop this condition from direct trauma or chemical irritation to the nerve root, inactivity, staying in certain positions too long, using poor body mechanics with lifting, or having weak core musculature. Regardless of the cause, it is important to get an accurate diagnosis in order to treat it correctly. Lumbar radiculopathy, like thoracic radiculopathy, can mimic other conditions, which require different treatments. In rare cases, lumbar radiculopathy can be caused by infection, cancer, vascular disease, or congenital abnormalities. Therefore, quality evaluation and diagnosis from a physician is vital.

What are the Symptoms?

The classic symptoms of lumbar radiculopathy are pain and/or numbness and tingling extending down the leg, with or without accompanying back pain. The compromised spinal nerve root results in pain, weakness, and/or impairment of sensory regions associated with the affected nerve root. The muscles of the back, hip, thigh, and calf may be tight or feel like they are in spasm. This is more likely a result of irritated nerve rather than actual muscle tightness. Typically, the symptoms worsen with certain positions or activities, such as sitting or standing for long periods. Sometimes even lying flat to rest can increase symptoms. When the bones in the spine undergo the aging process, the spaces for nerves and the spinal cord to run through may narrow (spinal stenosis) and impinge nerves on both sides. In these cases, people can experience pain, heaviness, and/or numbness and tingling in both legs while standing upright or walking, which is called neurogenic claudication. The most commonly affected nerve with lumbar radiculopathy is the sciatic nerve, which is where sciatica gets its name. Symptoms specific to impingement of nerve roots of the sciatic nerve are pain and/or numbness and tingling starting in the low back, then radiating into the buttocks, and shooting down the back of the leg into the foot. This can be confused with piriformis syndrome or hamstring syndrome, which also affect the sciatic nerve, but not at the nerve roots. Often people with lumbar radiculopathy experience no back pain but have numbness and tingling in their legs and feet, which explains why people might not initially consider the low back as the source of their pain. It can feel like peripheral neuropathydiabetic neuropathy, or Tarsal Tunnel Syndrome. However, these conditions are distinct from lumbar radiculopathy and should be treated as such. Neuropathy describes damage to or disease of peripheral nerves, which are outside the spine. Tarsal Tunnel Syndrome, as discussed later, is caused by compressed nerve in the foot. Other more serious conditions should also be ruled out in cases of numbness and tingling in the feet, such as Guillain-Barre Syndrome, autoimmune disease, and infection.


Treatment for lumbar radiculopathy, like in the rest of the spine, is symptom-based. In the early stages, the primary goals are to reduce pain and restore any loss of sensation. This can be accomplished through medications, epidural injections, application of topical analgesics, and education on staying active/exercise. Physical therapy can help with reducing neural tension (pain caused by nerve irritation), releasing muscle tightness, and improving strength in core muscles. Research has shown that core musculature weakens during episodes of low back pain, which increases vulnerability to future episodes of radiculopathy. Mechanical traction and spinal manipulation may be used by physical therapists or chiropractors and can relieve symptoms in the short-term. Surgery may be used to decompress a nerve or fuse an unstable spinal segment. While statistics show that lumbar surgery is safe and effective in short-term, it has shown no long-term benefits for pain and function.

Other Types of Impingement

holding wrist

Carpal Tunnel Syndrome

Carpal tunnel syndrome is nerve compression at the wrist. Here, the median nerve passes through bones and tendons and can become entrapped. Sitting at a computer for extended periods increases the risk, which may explain why it is the most reported nerve entrapment syndrome. It is also the most expensive upper extremity disorder in the United States, costing over $2 billion annually. In addition to desk job workers, others at increased risk are industrial workers and elderly. Symptoms include numbness and tingling in one or both hands, weakness of the hands and fingers, and wrist stiffness. Treatment includes activity modification, splinting, ergonomic modifications, occupational therapy, injections, and in serious cases, surgery. When evaluating, clinicians should rule out neck problems, as they can mimic carpal tunnel syndrome.

Tarsal Tunnel Syndrome

Though much less reported than carpal tunnel syndrome, tarsal tunnel syndrome is a nerve entrapment syndrome that often goes undiagnosed because it gets missed. The posterior tibial nerve travels behind the inner ankle bone, where three other ankle muscle tendons also pass through. In anatomical terms, this is called the tarsal tunnel. In the tunnel, the nerve branches into three segments. When compressed, it can cause pain and/or numbness and tingling in any or all three segments, which affect the ankle and foot. Treatment includes physical therapy for stretching tight structures that may be compressing the nerve, strengthening weak muscles to avoid compensations, injection, and surgical release if necessary. Perhaps most important in treating this issue is getting an accurate diagnosis, as it may be assumed to be a pinched nerve in the back.

If you are experiencing pain that you want to discuss further, please make an appointment with Dr. Connor.

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