Diabetic peripheral neuropathy is one of the most common complications of diabetes and one of the leading causes of foot ulcers, infections, Charcot foot, and lower extremity amputation. Because nerve damage often develops gradually and without pain, many patients are unaware they have lost protective sensation until a serious complication occurs.
Early evaluation by a foot and ankle physician can identify neuropathy before ulcers develop and establish a preventive care plan that helps reduce the risk of limb-threatening complications.
Diabetics may lose sensation in their feet, usually starting at the toes. This may cause them not to feel sharp objects that can hurt them. It is important to check the feet each day for foreign bodies, bleeding, signs of infection, and call the doctor right away if the above are seen. Diabetic neuropathy can also cause painful burning and tingling, and may de-regulate blood flow, causing a Charcot foot when there is too much blood flow.
If you have diabetes and experience painful prickling, heaviness, tiredness or other uncomfortable symptoms in your feet, you may have peripheral neuropathy, or nerve damage caused by diabetes. Diabetes can have serious complications in the feet, so people with diabetes should have a regular annual exam with a podiatrist and contact their podiatrist any time they notice a change in their feet.
Diabetic neuropathy affects much more than the nerves. It changes foot mechanics, skin health, balance, pressure distribution, and the ability to detect injuries. Although diabetes is managed by primary care physicians and endocrinologists, regular evaluation by a foot and ankle physician focuses on preventing the complications that most commonly lead to hospitalization and limb loss.
Why Early Foot Evaluation Matters
Many patients believe numbness is simply an unavoidable part of diabetes. In reality, loss of protective sensation dramatically increases the risk of:
- unnoticed injuries
- skin breakdown
- diabetic foot ulcers
- Charcot foot
- bone infection
- amputation
Regular foot examinations can identify these problems before they become emergencies.
What Is Diabetic Peripheral Neuropathy?
Diabetic neuropathy is nerve damage caused by diabetes. When it affects the arms, hands, legs and feet, it is known as diabetic peripheral neuropathy. Diabetic peripheral neuropathy is different from peripheral arterial disease (poor circulation), which affects the blood vessels rather than the nerves.
Three different groups of nerves can be affected by diabetic neuropathy:
- Sensory nerves, which enable people to feel pain, temperature and other sensations
- Motor nerves, which control the muscles and give them their strength and tone
- Autonomic nerves, which allow the body to perform certain involuntary functions, such as sweating
Diabetic peripheral neuropathy does not emerge overnight. Instead, it usually develops slowly and worsens over time. Some patients have this condition long before they are diagnosed with diabetes. Having diabetes for several years may increase the likelihood of having diabetic neuropathy. The loss of sensation and other problems associated with nerve damage make a patient prone to developing skin ulcers (open sores) that can become infected and may not heal. This serious complication of diabetes can lead to loss of a foot, a leg or even a life.
Causes
The nerve damage that characterizes diabetic peripheral neuropathy is more common in patients with poorly managed diabetes. However, even patients living with diabetes who have excellent blood sugar (glucose) control can develop diabetic neuropathy. There are several theories as to why this occurs, including the possibilities that high blood glucose or constricted blood vessels produce damage to the nerves.
As diabetic peripheral neuropathy progresses, various nerves are affected. These damaged nerves can cause problems that encourage development of ulcers. For example:
- Deformities (such as bunions or hammertoes) resulting from motor neuropathy may cause shoes to rub against toes, creating a sore. The numbness caused by sensory neuropathy can make the patient unaware that this is happening.
- Because of numbness, a patient may not realize that s/he has stepped on a small object and cut the skin.
- Cracked skin caused by autonomic neuropathy, combined with sensory neuropathy’s numbness and problems associated with motor neuropathy, can lead to developing a sore.
Motor Neuropathy (Deformity) + Ill-Fitting Shoes + Sensory Neuropathy (numbness) = Ulcers (sores)
Symptoms
Depending on the type(s) of nerves involved, one or more symptoms may be present in diabetic peripheral neuropathy.
For sensory neuropathy:
- Numbness or tingling in the feet
- Pain or discomfort in the feet or legs, including prickly, sharp pain or burning feet
For motor neuropathy:
- Muscle weakness and loss of muscle tone in the feet and lower legs
- Loss of balance
- Changes in foot shape that can lead to areas of increased pressure
For autonomic neuropathy:
- Dry feet
- Cracked skin
Diagnosis
Diagnosis involves more than confirming nerve damage. A comprehensive diabetic foot evaluation also identifies structural deformities, abnormal pressure areas, circulation problems, skin changes, footwear issues, and early signs of ulcer formation that frequently accompany diabetic neuropathy.
- protective sensation testing
- monofilament testing
- vibration
- reflexes
- circulation
- biomechanics
- skin evaluation
- footwear evaluation
- ulcer risk classification
Because diabetic neuropathy often affects multiple aspects of foot health simultaneously, evaluation is most effective when nerve function, circulation, biomechanics, skin integrity, and ulcer risk are assessed together. A foot and ankle physician coordinates these findings while working closely with primary care physicians, endocrinologists, neurologists, vascular specialists, and wound care teams whenever additional care is needed.
Treatment may include
- glucose control
- education
- protective footwear
- pressure reduction
- orthotics
- treatment of deformity
- ulcer prevention
- medications for painful neuropathy
- fall prevention
- regular surveillance
Prevention
The patient plays a vital role in minimizing the risk of developing diabetic peripheral neuropathy and in preventing its possible consequences. Some important preventive measures include:
- Keep blood sugar levels under control.
- Wear well-fitting shoes to avoid getting sores.
- Inspect your feet every day. If you notice any cuts, redness, blisters or swelling, see your foot and ankle surgeon right away. This can prevent problems from becoming worse.
- Visit your foot and ankle surgeon on a regular basis for an examination to help prevent the foot complications of diabetes.
- Have periodic visits with your primary care physician or endocrinologist. The foot and ankle surgeon works together with these and other providers to prevent and treat complications from diabetes.
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Frequently Asked Questions
Diabetic peripheral neuropathy usually cannot be completely reversed because damaged nerves have a limited ability to regenerate. However, controlling blood sugar, maintaining a healthy lifestyle, and treating contributing factors can slow progression and, in some cases, improve symptoms. Early diagnosis is important because prompt treatment can help prevent serious complications such as foot ulcers, infections, Charcot foot, and amputation.
No. While diabetes is one of the most common causes of peripheral neuropathy, numbness in the feet can also result from vitamin deficiencies, nerve compression, spinal disorders, certain medications, alcohol use, autoimmune diseases, poor circulation, and other neurologic conditions. A comprehensive evaluation can help determine the underlying cause and identify any foot problems that require treatment.
Yes. The nerves in your feet provide important sensory information that helps you maintain balance while standing and walking. When protective sensation is lost, it becomes more difficult to detect the position of your feet, increasing the risk of instability and falls. Muscle weakness, foot deformities, and poor circulation may further affect balance. Regular foot evaluations can identify these changes early and help reduce the risk of injury through appropriate footwear, orthotics, and preventive care.
By itself, diabetic neuropathy does not cause amputation. However, the loss of protective sensation can allow cuts, blisters, pressure sores, or injuries to go unnoticed. These wounds may become infected, fail to heal, and progress to ulcers, bone infection (osteomyelitis), gangrene, or Charcot foot. Without timely treatment, these complications can become limb-threatening. Regular evaluation by a foot and ankle physician can help detect problems early and significantly reduce the risk of amputation through preventive care and prompt treatment.
Neurologists evaluate disorders of the nervous system and may help diagnose or manage the nerve condition itself. A foot and ankle physician focuses on preventing and treating the complications diabetic neuropathy causes in the feet, including ulcers, deformity, Charcot foot, infections, and limb preservation. Many patients benefit from coordinated care involving both specialists when appropriate.
When to Schedule a Diabetic Foot Evaluation
- New numbness
- Burning feet
- Tingling
- Balance changes
- Foot deformity
- Previous ulcer
- Callus formation
- Diabetes for many years
- Difficulty inspecting your feet
Early evaluation can identify problems before they become serious and help reduce the risk of ulcers, infection, and amputation.
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