Sunday, March 03, 2024
DIABETES Diabetic Neuropathy

Diabetic Neuropathy in the Feet- A Simple Treatment Guide

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Peripheral neuropathy is damage to the peripheral nerves in the body. Diabetic neuropathy is a complication that can occur in people who have diabetes.

Diabetic peripheral neuropathy is the most common cause of neuropathy worldwide. It is estimated to be present in approximately half of those with diabetes (1).

diabetes

There are different kinds of diabetic neuropathy including sensory/motor neuropathy, autonomic neuropathy, and mononeuropathy. 

For this article, we’ll discuss the most common neuropathy seen in diabetics: Distal Sensory Polyneuropathy.

People who have distal sensory polyneuropathy can have nerve pain or numbness in their legs and feet. Neuropathy can also cause muscle weakness.

Neuropathy in the feet can affect your quality of life. It’s important to address your symptoms early to prevent the condition from worsening. 

In this article, we’ll discuss diabetic neuropathy and how it affects the feet. In addition, we’ll discuss treatment options for neuropathy as well as steps you can take to practice good foot health. 

Let’s dive in…

How Is Diabetes Diagnosed?

Since diabetic neuropathy occurs in diabetics, it’s important to understand how diabetes itself is diagnosed.

The American Diabetes Association classifies diagnosis of diabetes as fasting blood glucose levels of greater than 126mg/dL (fasting for 8 hours), or a 2-hour plasma glucose level greater than 200mg/dL during an Oral Glucose Tolerance Test. 

Another indicator of diabetes is a Hemoglobin A1c level greater than 6.5.

A hemoglobin A1c test measures your average blood sugar in the last 3 months.

Check out this conversion table that converts your Hemoglobin A1c number to blood sugar readings in mg/dL.

neuropathy clipboard

What Causes Diabetic Neuropathy?

When you have chronically elevated blood sugar levels, this can cause your nerves to become damaged. There are sensory nerves in your body that are responsible for touch, pain, pressure, and temperature sensations. 

If you step on something sharp, the signals in your sensory nerves notify your brain of injury to the body. In someone who has severe neuropathy, your body would be unable to tell that it is injured due to nerve damage.

There are also motor nerves that are responsible for motor function in the legs and feet. These nerves assist with the movements of your muscles and allow you to do things like moving your ankle up and down. 

The motor nerves also help with balance and stabilization. This is important when you are standing and walking. Diabetic neuropathy with motor nerve dysfunction can impact your balance negatively. Not only that, it can place you at high risk for falls. 

person holding glucose meter

When Do Diabetics Develop Neuropathy Symptoms in the Feet?

Diabetic neuropathy symptoms often start in the first 10 years after one is diagnosed with diabetes. However, a higher-than-average blood sugar number can place you at risk for diabetic neuropathy. 

Some people even experience diabetic neuropathy when they are prediabetic. N. Papanas in Nature Reviews Endocrinology states that “Between 25% and 62% of patients with idiopathic peripheral neuropathy are reported to have prediabetes, and among individuals with prediabetes 11–25% are thought to have peripheral neuropathy, and 13–21% have neuropathic pain (2).

What Does Diabetic Sensory and Motor Neuropathy in the Feet Feel Like?

  • Pins and needles sensation
  • Numbness in the feet/legs
  • Burning pain
  • A “dead” feeling in the feet
  • Cramping
  • Sharp stabbing pain 
  • Inability to distinguish between hot and cold sensations
  • Touch sensitivity
  • A “buzzing” sensation in the feet
  • Feeling like you are walking on sand
  • Feeling like you are wearing socks when you are not
  • Feeling like your feet is wet when it is not
  • Muscle weakness
  • Weak Achilles tendon reflexes
  • Feeling unstable while standing and walking

Is Diabetic Neuropathy Constant or Intermittent?

In the early stages, diabetic neuropathy can be intermittent. Many people do not seek care in the initial stages because the neuropathy is intermittent and only causes occasional discomfort. Many people live with the pain as it usually doesn’t interfere with their activities until the later stages. 

If your blood sugars continue to be elevated, further nerve damage can occur, and neuropathy can cause constant pain. You may feel pain throughout the day. As the neuropathy progresses, it can be difficult to perform daily tasks. 

If you develop severe neuropathy, your feet and legs may become completely numb. This can place you at a very high risk for ulceration. Not only that, you may struggle with balance issues, and even walking may become difficult. 

Where Does Diabetic Neuropathy Usually Start?

Diabetic neuropathy will usually start in your toes. If the neuropathy worsens, you may experience pain and even numbness extending into your legs. Weakness of the intrinsic muscles in the feet can occur in people who suffer from diabetic neuropathy.

If the neuropathy worsens, you may notice weakness in your Achilles tendon and also the muscles in your legs. 

testing sensation feet

How Do You Test for Foot Neuropathy?

Your doctor will obtain a history and physical to determine the severity of neuropathy. He/she will use a Semmes Weinstein Monofilament 5.07/10g wire to test different areas in your feet to see if you feel pressure. Lack of sensation indicates the presence of neuropathy. 

Your doctor will also check if you can distinguish between a sharp and dull sensation by breaking a cotton tip applicator and lightly pressing the sharp and dull end against your feet.  

Vibration sensation will also be tested. Your doctor will use a tuning fork and apply it to your toe to see if you can feel a vibration sensation. 

Your doctor will also check your patellar and Achilles tendon reflexes. He/she will be looking for any weakness or absence of reflexes. 

Your doctor will also examine how you walk and note any balance issues that may be present.

Your doctor may order blood work to rule out other causes of neuropathy such as Vitamin B12 deficiencies. 

Occasionally, a Nerve Conduction Velocity test (NCV) and Electromyography test (EMG) may be ordered to confirm the presence of neuropathy. Nerve conduction tests can measure the intensity of nerve signals as well as speed. An EMG test can assess how the muscles respond to nerve signals. Both tests can help confirm neuropathy.

How Quickly Does Neuropathy Progress?

Neuropathy can progress and worsen in a matter of several months to several years. Neuropathy progression depends on the health of the patient with diabetes as well as their blood sugar levels. Chronically elevated blood sugar levels can cause excessive damage to the nerves. Due to this, some people with diabetes may experience neuropathic pain and weakness fairly quickly. 

Can You Reverse Diabetic Foot Neuropathy?

As of right now, diabetic neuropathy cannot be reversed. Your body cannot repair nerve damage once it occurs. However, there are plenty of oral and topical treatments that are effective in managing diabetic neuropathy symptoms. When caught and treated early, diabetic neuropathy can be effectively managed.

diabetes pills

Treatment of Diabetic Neuropathy in the Legs and Feet

Oral Medications

Anti-convulsant Drugs

Pregabalin (Lyrica) and Gabapentin (Neurontin) are effective drugs that can help treat diabetic neuropathy. Both are anticonvulsant drugs and are beneficial in people who suffer from diabetic neuropathy.

Pregabalin is FDA approved for diabetic neuropathy. Gabapentin, although not FDA-approved specifically for diabetic neuropathy, is still effective in alleviating painful neuropathy symptoms. 

Some of the side effects of these medications include fatigue, sleep, nausea, mood changes, and blurred vision. Your doctor will choose which medication would be best for you and will start you on a low dose. Your dosage may be increased to tolerance. 

Anti-depressant Drugs

Anti-depressants have also been shown to be effective against diabetic neuropathy. Duloxetine, which is used as an antidepressant is FDA approved to treat diabetic neuropathy. It can help alleviate and pain tingling associated with neuropathy. Amitriptyline is also effective in treating diabetic neuropathy. Some of the side effects include difficulty sleeping, blurred vision, nausea, headache, and feeling ill. 

Opioid Drugs

Occasionally, opioids may be used for pain associated with diabetic neuropathy. Tapentadol is FDA approved for diabetic nerve pain. It can also be used for chronic low back pain.

Another opioid that is effective for diabetic neuropathy is Tramadol. Tapentadol is 2-3 times stronger than Tramadol, and should only be used with close monitoring in people who suffer from severe nerve pain. Taking opioids regularly increases the risk for addiction. 

medication cream

Topical Medications

Capsaicin Cream

Capsaicin is found in peppers. Capsaicin cream can reduce nerve pain in the feet. Low-dose Capsaicin cream can be found in the drug store. When you apply the cream to your feet, it’s normal to experience some burning before pain relief.

Higher strength prescription Capsaicin 8% patches (Qutenza) are effective in reducing nerve pain. Be sure to speak to your doctor before using Capsaicin. 

Prescription Lidocaine creams and patches are beneficial in reducing nerve pain in the feet. Lidocaine cream is a local anesthetic that blocks pain signals in your body. You can purchase Aspercreme with Lidocaine 4% from the drug store. 

If you need something stronger, ask your doctor for a prescription for Lidocaine 5% ointment or Lidocaine patches.

Medical TENS unit

Other Treatments for Diabetic Neuropathy

Transcutaneous Electrical Nerve Stimulation (TENS)

A TENS unit is a machine containing electrodes that can be applied to the skin to deliver low-voltage electrical charges to the skin. TENS units can reduce pain signals and can be effective for diabetic neuropathy. TENS units can be used daily to provide pain relief. Ask your doctor before using a TENS unit for neuropathy.

Acupuncture

Acupuncture has been used to treat a variety of ailments, including diabetic neuropathy. Acupuncture can improve the body’s response to pain signals. Tiny needles are inserted into the skin at various pressure points in the body. This in turn can stimulate blood flow and relieve nerve pain. 

Alpha-Lipoic Acid

Alpha-lipoic acid is an antioxidant that is found naturally in the body. Many foods contain alpha-lipoic acid. Some of these foods include spinach, broccoli, potatoes, and tomatoes.

Taking Alpha-Lipoic acid supplements can be beneficial in helping improve insulin resistance in people with diabetes. It has also been shown to help improve symptoms associated with nerve damage.  

Footwear

Diabetic shoes and inserts are greatly beneficial in people who have diabetic neuropathy. Diabetic shoes are designed to accommodate foot deformities. They come in a variety of widths and are made of soft protective interiors that won’t irritate the skin. The outer soles are firm and supportive. 

Diabetic plastazote inserts help to prevent sheer and blisters. Custom plastazote inserts can be designed to reduce pressure points in the feet and help accommodate painful calluses and ulcers. 

Talk to your foot doctor to obtain a prescription for diabetic shoes and inserts.

To read more about how Bad Shoes Can Cause Foot Pain, check out this supplemental article.

person walking on brown pathway

Is Walking Good for Neuropathy?

Establishing a regular walking routine can help control your blood glucose levels and thus help prevent neuropathy progression. Walking can also help keep your leg and feet muscles strong. 

Walking can help reduce edema, which can also help alleviate nerve pain.

Aim to walk 150 minutes a week. However, if you have severe neuropathy, you should avoid prolonged walks due to balance issues.

Can Diabetic Neuropathy Lead To Amputation?

Due to the lack of sensation in the feet associated with diabetic neuropathy, there is a higher risk for ulceration development and amputation. Diabetes UK states that “a person living with diabetes is 20 times more likely to experience an amputation than someone without the condition”.

A foot ulcer can form due to repetitive pressure in the neuropathic feet. Diabetics with severe neuropathy cannot adjust the way they apply pressure when standing and walking due to a lack of sensation in their feet. 

In addition, motor neuropathy can cause foot deformities like bunions and hammertoes to occur. This can cause certain areas of the feet to take on more pressure. 

Puncture wounds can also happen more frequently in diabetics with neuropathy. 

If an ulceration forms in the foot, it can become infected. The infection can progress to the bone. If this occurs, long-term IV antibiotics and amputation of the infected bone may be needed. 

To read more about Osteomyelitis (Bone infection) In The Feet, check out this supplemental post. 

diabetic foot exam

How Often Should You Get a Foot Exam if You Have Diabetic Neuropathy?

If you have diabetic neuropathy, you should see your foot doctor at least once every 3-6 months. 

If you have peripheral vascular disease with neuropathy in your feet, you should see your doctor every 2-3 months. 

High-risk patients with ulcerations and neuropathy should be seen every month. 

Check out this risk classification table by Diabetes Care for more information. 

Conclusion

In conclusion, diabetic neuropathy should be addressed and treated early to prevent complications from occurring. Severe neuropathy can cause quality of life issues and should not be ignored. Maintaining blood glucose levels is essential to prevent the progression of neuropathy. Regular foot exams are needed to prevent foot complications associated with neuropathy. 

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Related article: Stabbing Pain on Side of Foot: Causes & Treatments of Sharp Foot Pain

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References

  1. Liu X, Xu Y, An M, Zeng Q. The risk factors for diabetic peripheral neuropathy: A meta-analysis. PLoS One. 2019 Feb 20;14(2):e0212574.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382168/#:~:text=Current%20studies%20suggest%20that%20the,body%20mass%20Index%20(BMI)
  2. Papanas, N., Vinik, A. & Ziegler, D. Neuropathy in prediabetes: does the clock start ticking early?. Nat Rev Endocrinol 7, 682–690 (2011).https://www.nature.com/articles/nrendo.2011.113#citeas
  3. Schreiber AK, Nones CF, Reis RC, Chichorro JG, Cunha JM. Diabetic neuropathic pain: Physiopathology and treatment. World J Diabetes. 2015 Apr 15;6(3):432-44. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4398900/
  4. Pop-Busui R, Boulton AJ, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM, Ziegler D. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care. 2017 Jan;40(1):136-154. https://pubmed.ncbi.nlm.nih.gov/27999003/
  5. Kamalarathnam, Sangeetha R.; Varadarajan, Suresh. Diabetic peripheral neuropathy in diabetic patients attending an urban health and training centre. Journal of Family Medicine and Primary Care: January 2022 – Volume 11 – Issue 1 – p 113-117. https://journals.lww.com/jfmpc/Fulltext/2022/01000/Diabetic_peripheral_neuropathy_in_diabetic.19.aspx
  6. Feldman, E.L., Callaghan, B.C., Pop-Busui, R. et al. Diabetic neuropathy. Nat Rev Dis Primers 5, 41 (2019). https://www.nature.com/articles/s41572-019-0092-1#citeas
  7. Silvio Inzucchi, MD, Julio Rosenstock, MD, Guillermo Umpierrez, MD, Diabetic Neuropathy, The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 5, 1 May 2012, Page 35A,https://academic.oup.com/jcem/article/97/5/35A/2536294
  8. Lazzarini PA, Crews RT, van Netten JJ, Bus SA, Fernando ME, Chadwick PJ, Najafi B. Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management. J Diabetes Sci Technol. 2019 Sep;13(5):869-880. https://pubmed.ncbi.nlm.nih.gov/31030546/
  9. Snyder MJ, Gibbs LM, Lindsay TJ. Treating Painful Diabetic Peripheral Neuropathy: An Update. Am Fam Physician. 2016 Aug 1;94(3):227-34. https://pubmed.ncbi.nlm.nih.gov/27479625/
  10. Edmonds, M. E., Roberts, V. C., & Watkins, P. J. (1982). Blood flow in the diabetic neuropathic foot. Diabetologia22(1), 9-15.https://link.springer.com/article/10.1007/BF00253862
  11. Andersen, H., Gjerstad, M. D., & Jakobsen, J. (2004). Atrophy of foot muscles: a measure of diabetic neuropathy. Diabetes care27(10), 2382-2385.https://diabetesjournals.org/care/article/27/10/2382/23213/Atrophy-of-Foot-MusclesA-measure-of-diabetic
  12. Piaggesi A, Romanelli M, Schipani E, Campi F, Magliaro A, Baccetti F, Navalesi R. Hardness of plantar skin in diabetic neuropathic feet. J Diabetes Complications. 1999 May-Jun;13(3):129-34.https://pubmed.ncbi.nlm.nih.gov/10509872/

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Vaishnavi Bawa
Dr. Vaishnavi Bawa is a Podiatrist who specializes in treating foot and ankle pathology. LifesLittleSteps mission is to educate the public about foot health in an easy-to-understand manner using evidence-based medicine.
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