Peripheral Neuropathy in the Feet: Causes, Symptoms and Foot Care
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Why Are My Feet Numb, Tingling or Burning?
Have you ever experienced pins and needles in your feet, a burning sensation in your toes, or the feeling that you are walking on cotton wool? Perhaps your feet feel unusually cold, even when they are warm to the touch, or you have noticed that you don't feel the ground beneath your feet quite as well as you used to.
These sensations can be signs of peripheral neuropathy, a condition caused by damage to the nerves that carry messages between the brain, spinal cord and the rest of the body.
Peripheral neuropathy commonly affects the feet and lower legs, sometimes progressing to involve the hands. It can affect your ability to feel temperature, pain, pressure and touch, and in some cases can also affect muscle strength and balance.
But what causes it? While diabetes is probably the best-known cause, there are actually numerous conditions, nutritional deficiencies and lifestyle factors that can contribute to nerve damage.
Let's take a closer look.
What exactly is peripheral neuropathy?
Your peripheral nervous system is made up of the nerves that extend from your brain and spinal cord to the rest of your body.
These nerves perform several important functions:
Sensory nerves allow you to feel touch, pain, pressure, temperature and vibration.
Motor nerves control muscle movement and help you maintain strength and coordination.
Autonomic nerves regulate involuntary functions such as sweating, blood pressure and circulation-related responses.
When these nerves become damaged, the messages they carry can become disrupted. This can result in altered sensation, pain, muscle weakness or changes in the way your body regulates certain functions.
Symptoms can include:
Numbness or reduced sensation in the toes or feet.
Pins and needles or tingling.
Burning, shooting or electric-shock-like sensations.
Increased sensitivity, where even the light touch of a bedsheet feels uncomfortable.
A sensation of walking on pebbles, padding or cotton wool.
Reduced awareness of temperature.
Muscle weakness, cramping or difficulty lifting the toes.
Poor balance or increased risk of falling.
Symptoms often begin in the toes and gradually spread upwards towards the ankles and legs.
This is because the longest nerves in the body are often affected first.
Not everyone experiences pain. Some people have considerable nerve damage without experiencing any discomfort at all.
What causes peripheral neuropathy?
There are many possible causes, and identifying the underlying reason is important because some forms of neuropathy can be treated or their progression slowed.
Here are some of the most common and important causes.
1. Diabetes
Diabetes is one of the leading causes of peripheral neuropathy.
Persistently elevated blood glucose levels can damage nerve fibres and the tiny blood vessels responsible for supplying them with oxygen and nutrients.
Over time, this can interfere with normal nerve function, resulting in diabetic peripheral neuropathy.
It is particularly associated with:
Poorly controlled blood glucose levels.
Having diabetes for many years.
Other associated risk factors, including smoking and excessive alcohol consumption.
Importantly, neuropathy doesn't necessarily mean that someone has poorly controlled diabetes. Nerve damage can develop even in people who are managing their blood glucose levels carefully.
In some cases, peripheral neuropathy can even be present before someone realises they have type 2 diabetes.
2. Vitamin B12 deficiency
Vitamin B12 is essential for maintaining healthy nerve tissue and producing myelin, the protective insulating layer surrounding many nerve fibres.
When B12 levels become too low, the nervous system can be affected, potentially resulting in numbness, tingling, altered sensation and problems with balance.
Vitamin B12 deficiency can develop for several reasons, including:
Inadequate dietary intake, particularly in people following a strict vegan diet without appropriate supplementation.
Problems absorbing B12 from the digestive system.
Pernicious anaemia, an autoimmune condition that affects B12 absorption.
Certain gastrointestinal conditions or previous stomach and bowel surgery.
Long-term use of certain medications, including metformin and some medicines used to reduce stomach acid.
One important point is that B12 deficiency can cause neurological symptoms even without the more familiar symptoms of anaemia.
Fortunately, when identified early, B12 deficiency can often be treated. However, nerve damage caused by prolonged deficiency may not always be completely reversible.
3. Alcohol consumption
Long-term excessive alcohol consumption can damage peripheral nerves.
Alcohol can have a direct toxic effect on nerve tissue and can also contribute to nutritional deficiencies, particularly deficiencies of B vitamins such as thiamine (vitamin B1).
Alcohol-related neuropathy commonly affects both feet and may cause:
Burning or painful sensations.
Numbness and tingling.
Muscle weakness.
Reduced reflexes.
Problems with balance and coordination.
Reducing or stopping alcohol consumption, alongside addressing any nutritional deficiencies, may help prevent further damage.
4. Vitamin deficiencies and nutritional imbalances
Although B12 is particularly important, other nutritional deficiencies can also affect nerve health.
These include deficiencies of:
Vitamin B1 (thiamine).
Vitamin B6 (pyridoxine).
Vitamin E.
Copper.
Interestingly, vitamin B6 can cause neuropathy at both ends of the spectrum. While inadequate levels can affect nerve function, excessive vitamin B6 intake can also cause sensory nerve damage.
This is particularly relevant to people taking multiple supplements, as vitamin B6 is found in many multivitamin preparations, B-complex supplements and products marketed for nerve health.
Taking more vitamins isn't necessarily better!
5. Thyroid disorders
An underactive thyroid (hypothyroidism) can sometimes contribute to peripheral neuropathy.
When thyroid hormone levels are too low, various metabolic processes throughout the body slow down. This can affect nerve function and, in some cases, contribute to nerve damage.
People with hypothyroidism may experience tingling, numbness, burning sensations or muscle weakness.
Thyroid disorders can often be identified through a simple blood test and treated with appropriate medication.
6. Kidney and liver disease
Both the kidneys and liver play important roles in removing waste products and maintaining the body's internal chemical balance.
When kidney function becomes significantly impaired, waste products can accumulate in the bloodstream. This can affect the nervous system and lead to a condition known as uraemic neuropathy.
Chronic liver disease can also be associated with peripheral nerve damage.
In these circumstances, neuropathy may be one of several symptoms associated with an underlying systemic condition.
7. Nerve compression, injury and spinal problems
Not all nerve problems originate from a systemic medical condition.
Individual nerves can become compressed, irritated or damaged following injury, surgery or prolonged pressure.
Examples include:
Tarsal tunnel syndrome: Compression of the tibial nerve as it passes through a narrow anatomical space on the inside of the ankle. This can cause burning, tingling or numbness in the sole of the foot.
Morton's neuroma: Irritation and thickening of the tissue surrounding a nerve between the metatarsal bones, commonly causing burning pain, tingling or the sensation of a pebble beneath the ball of the foot.
Lumbar nerve compression: Problems involving the lower back, such as a slipped disc or spinal stenosis, can irritate or compress nerve roots and cause pain, tingling or numbness extending into the legs and feet.
Trauma or surgery: Direct injury to a nerve can cause altered sensation in the area supplied by that nerve.
These conditions are not necessarily the same as a generalised peripheral polyneuropathy, but they can produce similar symptoms and are important considerations when investigating foot-related nerve problems.
8. Autoimmune and inflammatory conditions
Sometimes the body's immune system mistakenly attacks its own tissues, including components of the nervous system.
A number of autoimmune and inflammatory conditions can be associated with peripheral neuropathy, including:
Rheumatoid arthritis.
Systemic lupus erythematosus.
Sjögren's syndrome.
Coeliac disease.
Vasculitis (inflammation of the blood vessels).
In some cases, the immune system directly damages nerve tissue. In others, inflammation surrounding the nerves can contribute to nerve compression or impaired blood supply.
9. Infections
Certain infections can cause nerve damage, either directly or through an abnormal immune response.
Examples include:
Shingles, caused by reactivation of the varicella-zoster virus.
Lyme disease.
HIV.
Hepatitis C.
Certain other bacterial and viral infections.
Some infections can also trigger an immune-mediated condition called Guillain-Barré syndrome, which can cause rapidly developing nerve damage and muscle weakness.
10. Medication and chemotherapy
Certain medications can cause peripheral neuropathy as an unwanted side effect.
These include some chemotherapy drugs, as well as certain antibiotics and other long-term medications.
Examples include:
Some chemotherapy agents used to treat cancer.
Metronidazole, particularly with prolonged use.
Nitrofurantoin, particularly with prolonged use.
Phenytoin.
Amiodarone.
Not everyone taking these medications will develop neuropathy, and the risk varies depending on the drug, dosage and duration of treatment.
If you suspect that medication may be contributing to your symptoms, speak to your GP or prescribing clinician. Never discontinue prescribed medication without seeking medical advice.
11. Hereditary conditions
Some forms of peripheral neuropathy are inherited.
One example is Charcot-Marie-Tooth disease (CMT), a group of genetic conditions affecting the peripheral nerves.
CMT commonly affects the feet and lower legs, potentially causing:
High-arched feet.
Curled or clawed toes.
Muscle wasting around the feet and lower legs.
Foot drop.
Reduced sensation.
Problems with walking and balance.
Symptoms often develop gradually and may become more noticeable over time.
A family history of similar foot shapes, walking difficulties or unexplained nerve problems can sometimes provide an important diagnostic clue.
12. Idiopathic neuropathy – when no cause can be found
Despite investigations, it isn't always possible to establish why someone has developed peripheral neuropathy.
When no identifiable underlying cause can be found, it is described as idiopathic peripheral neuropathy.
This is particularly encountered in older adults, although it can occur at other ages too.
An absence of an obvious cause doesn't mean that symptoms should be ignored. Ongoing monitoring and appropriate foot care remain important.
How is peripheral neuropathy diagnosed?
If you are experiencing persistent numbness, tingling, burning or altered sensation in your feet, it is important to arrange an appointment with your GP.
Identifying the underlying cause is an important part of the diagnostic process.
Your GP may:
Take a detailed medical history, including your medications and any family history of neurological conditions.
Assess your muscle strength, reflexes and sensation.
Arrange blood tests to investigate possible causes.
Blood tests may include checks for:
Blood glucose and HbA1c (to investigate diabetes).
Vitamin B12.
Thyroid function.
Kidney and liver function.
Inflammation and other relevant markers.
Depending on the findings, further investigations may be necessary. These can include nerve conduction studies, electromyography (EMG) or referral to a neurologist.
The appropriate investigations will depend on your symptoms and medical history.
Why is peripheral neuropathy particularly important for foot health?
One of the biggest concerns with peripheral neuropathy is that reduced sensation can leave the feet vulnerable to injuries that might otherwise be noticed immediately.
For example, imagine walking around with a small stone inside your shoe. Most people would quickly notice the discomfort and remove it.
However, someone with significant sensory neuropathy may not feel the stone at all.
The same applies to:
Blisters caused by ill-fitting footwear.
Cuts and abrasions.
Burns from hot water or heating appliances.
Pressure-related damage beneath areas of hard skin and callus.
Small wounds that develop into more serious ulcers.
If protective sensation is reduced, injuries can go unnoticed and potentially become infected.
This is why regular foot assessments are particularly important for people with peripheral neuropathy, especially those with diabetes.
What can be done to protect your feet?
Whether or not the underlying cause of neuropathy can be reversed, there are several practical steps you can take to help protect your feet.
1. Check your feet regularly
Look for cuts, blisters, redness, swelling, changes in skin colour and areas of excessive pressure. Remember to check between your toes and around your heels.
If you have difficulty seeing the soles of your feet, use a mirror or ask someone to help.
2. Choose appropriate footwear
Wear well-fitting shoes that provide adequate protection and support. Avoid shoes that rub, squeeze your toes or create excessive pressure.
3. Be careful with temperature
Reduced sensation can make it difficult to judge how hot water or other heat sources are. Always check bath water temperature carefully and avoid placing hot water bottles or heating pads directly against your feet.
4. Don't ignore hard skin
Callus can develop in areas of increased pressure. If you have reduced sensation, excessive callus should be assessed by a podiatrist rather than attempting to remove it yourself with blades, corn plasters or other chemical preparations.
5. Keep your skin moisturised
Dry, cracked skin can provide an entry point for infection. Regularly applying an appropriate moisturiser can help maintain the skin barrier. Avoid applying moisturiser between the toes.
6. Arrange regular podiatry assessments
A podiatrist can assess your skin, nails, circulation, sensation and areas of pressure, helping to identify potential problems before they become more serious.
Can peripheral neuropathy be reversed?
This depends largely on the underlying cause and the extent of nerve damage.
In some cases, treating the underlying problem can improve symptoms or prevent further deterioration. For example, correcting a vitamin B12 deficiency, improving diabetic control or addressing medication-related nerve damage may help.
However, when nerve damage has been present for a long time, it may be permanent.
Even when nerve damage cannot be reversed, appropriate medical management, symptom control and preventative foot care can make a significant difference to quality of life.
When should you seek medical advice?
Don't dismiss persistent tingling, numbness, burning or altered sensation in your feet as simply part of getting older.
Arrange an appointment with your GP if you notice:
Persistent pins and needles or numbness.
Burning or unexplained pain in your feet.
A reduction in your ability to feel touch, temperature or pressure.
Changes in balance or walking ability.
Unexplained muscle weakness.
Seek urgent medical assessment if you develop rapidly progressing weakness, sudden foot drop or rapidly spreading numbness. New back pain accompanied by numbness around the saddle area, bladder or bowel disturbance, or weakness in both legs requires emergency assessment.
A foot wound that is not healing, particularly if you have diabetes or reduced sensation, also needs prompt medical attention.
How can Oxfordshire Chiropody & Podiatry help?
At OCP, we understand that healthy feet involve much more than simply looking after your toenails.
Peripheral neuropathy can have a significant impact on foot health, mobility and independence. A thorough podiatry assessment can help identify changes in sensation, areas of increased pressure, skin damage and other potential complications.
We can assess your protective sensation, examine your circulation, identify potential pressure-related problems and advise on appropriate footwear and preventative foot care.
If we identify any concerns, we can recommend further medical investigation or liaise with your GP where appropriate.
Your feet shouldn't be ignored simply because they aren't hurting. Sometimes, a loss of sensation is just as important as pain.
If you've noticed changes in the way your feet feel, don't hesitate to arrange an assessment.
This article is intended for general information and educational purposes. It is not a substitute for an individual medical assessment or diagnosis.
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