Diabetic neuropathy may be common, but it isn’t something we should take lightly. It can be very painful and can put you at risk for other serious complications including infections and amputations.
The American Diabetes Association (ADA) estimates that about half of everyone with diabetes — type 1 and type 2 — have some degree of neuropathy or “nerve damage.”
In this article, we’ll look at the signs and symptoms of neuropathy, how it’s diagnosed, how it’s treated, how to prevent further complications, and how to stay active despite long-term pain.
What is diabetic neuropathy?
There are two types of neuropathy most commonly associated with diabetes:
- Peripheral Neuropathy: “Peripheral neuropathy can cause tingling, pain, numbness, or weakness in your feet and hands,” says the ADA.
- Autonomic Neuropathy: “Autonomic neuropathy affects the nerves in your body that control your body systems,” says the ADA.
The most common form, which we’ll focus on in this article, is “peripheral neuropathy.”
Peripheral neuropathy — also referred to as “diabetic neuropathy” or “PN” — is severe nerve damage and limited blood flow to your hands, finger, toes, feet, legs, and arms.
You’re most at risk for developing neuropathy if…
A1c levels persistently above 8 percent year after year, increases your risk of neuropathy significantly. A1c levels above 10 percent year after year are a near guarantee for severe and rapid development of neuropathy.
Mostly, it develops in those whose blood sugars have been elevated for a number of years, or in those who have simply lived with diabetes for several decades.
While neuropathy can develop in those who have healthy blood sugar levels, it’s less common. However, several decades of well-managed diabetes can still result in mild-to-moderate neuropathy for some.
In people with diabetes, neuropathy also tends to go hand-in-hand with obesity and high blood pressure.
Neuropathy can also be the result of non-diabetes related conditions like a severely nutrient-deficient diet, toxic chemical exposure, kidney failure, chronic alcoholism, and medications used to treat HIV and AIDS.
Steps to prevent diabetic neuropathy
Reduce your A1c: The best way to prevent neuropathy or severe neuropathy is by managing your blood sugars tightly enough to keep your A1c below 8 percent — and ideally below 7 percent.
Limit your alcohol consumption: Limiting your alcohol consumption to no more than 1 drink per day for women and 2 drinks per day for men. Ideally, striving to only drink a couple of drinks over an entire week will help anyone dramatically improve their health, especially those of us with diabetes.
Quit smoking right now.
Get active: Exercise increases blood flow which helps get vital nutrients and fresh blood to your fingers and toes. It also helps to lower your blood sugars, lose weight, and lower your blood pressure.
Eat a mostly healthy diet: Don’t overthink it or feel like you’ve got to join a cultish diet trend. The gist is simple: try to consume mostly whole, real foods. More vegetables. Fewer visits to fast-food restaurants. More homecooked meals. You don’t have to eat the perfect diet. Aim for the 80/20 rule: 80 percent healthy choices with room for 20 percent of your choices being less than perfect to prevent feeling deprived. Long-term nutrition success is about balance, not perfection.
Take your insulin and diabetes medications as prescribed: If your blood sugars are consistently high or low, talk to your healthcare team immediately to help get them adjusted. Our insulin needs and medication needs can change if our habits change. If you lose weight or gain weight, for example, your medication needs will likely need an adjustment.
And check your blood sugars often!
Symptoms of neuropathy in people with diabetes
The earliest signs and symptoms of neuropathy are fortunately easy to identify in affected areas. Keep in mind that you may feel some or all of the following symptoms, and the severity of your symptoms may increase if they are ignored and the neuropathy worsens.
- “Freezing” pain
- Sharp “electric” stinging
- Very sensitive to touch
- Eventual loss of feeling
- Eventual loss of balance in muscles of the affected area
- Eventual weakness in muscles of the affected area
The symptoms, however, are not necessarily constant, especially in the early development of the condition. Symptoms, like burning or stinging, can come and go, or only occur during certain parts of the day.
This can make them easier to dismiss and ignore at first — but you should report these “coming and going” symptoms to your healthcare team as early as possible.
It can be scary to acknowledge the symptoms but doing so may mean saving the sensation and use of your fingers, hand, toes, foot, or leg.
Early intervention means you can stop the progression of your neuropathy before it gets worse.
Diagnosing diabetic neuropathy
There are a few ways to determine that your symptoms are indeed the result of neuropathy.
The first test is simple: a neurological examination. Your doctor (generally your primary care or endocrinologist) will use a safe but sharp instrument to gently touch different areas around your feet, legs, toes, hands, and fingers.
With your eyes closed, you’ll tell your doctor what you can feel. This will help your healthcare team determine which parts of your body are most affected by neuropathy. This test will also include asking you to demonstrate the balance and strength in your feet, muscle tone, coordination, and posture.
Regarding your feet, part of your physical examination for diagnosing neuropathy will definitely involve looking for signs of injury based on these 3 issues:
- Loss of the ability to sense vibration and movement in the toes or feet (eg, when the toe is moved up or down)
- Loss of the ability to sense pain, light touch, and temperature in the toes or feet
- Loss or reduction of the Achilles tendon reflex
For many patients, additional scans may not be necessary beyond the physical examination.
The second test uses different devices to asses your nerve function. This detects nerve damage using a probe that sends an electrical signal to a nerve. An electrode is placed along that nerve’s pathway, recording the nerve’s response to the signal. Also known as “electromyography,” this test can involve some light pricking or tingling sensations but is not generally painful.
Other tests to determine nerve function include autonomic reflex tests, a sweat test, and sensory tests that measure your body’s response to touch, changes in temperature, and vibration.
For many people with diabetes, these additional tests may not be necessary simply because the root cause of your nerve function issues are not a mystery.
For people without diabetes, neuropathy can be more mysterious and require additional testing to rule out other causes like pinched discs in your spine or tumors that may be limiting the blood supply to a nerve or entire part of the body.
Treatment for the pain of neuropathy
Treating neuropathy can be simple for some and complicated for others depending on the severity of the condition at the time you are seeking treatment. Again, that’s why it’s so important to tell your doctor about your symptoms earlier than later.
Over-the-counter medications: Acetaminophen (commonly known under the brand name Tylenol) can be helpful for mild to moderate neuropathy pain. It works by blocking messages of pain from being sent to the brain. However, taking large doses of acetaminophen on a longterm basis can lead to liver damage. This approach to treating neuropathy should be done carefully and discussed with your healthcare team to prevent over-consumption.
NSAIDS (non-steroidal anti-inflammatory drugs): NSAIDS (commonly known under brand names including Advil, Motrin, Aleve) works by reducing inflammation and reducing pain by way of reducing the production of prostaglandins — a chemical made by the body that results in pain. However, long-term use of NSAIDS can result in stomach ulcers, nausea, diarrhea, and fatigue. This approach to treating neuropathy should be done carefully and discussed with your healthcare team to prevent over-consumption.
Topical medications: Creams containing ingredients like capsaicin derived from chili peppers can provide temporary relief for the burning and stinging pain of neuropathy. It is not going to reduce your pain long-term but can work well for a topical “in the moment” pain management.
Gabapentin: This is a very common method of treating nerve pain, and fortunately the side-effects are fairly mellow. Originally intended as an “anti-seizure” medication, it works to block the signals of nerve to the brain. It’s used for all kinds of nerve pain issues — even, for example, in patients after having knee surgery where nerve pain can be at its most intense. The primary side-effect is that it will make you drowsy, so it’s generally taken at night, which will also help you get better sleep during nerve pain.
Duloxetine: Approved by the FDA specifically for use in treating diabetic neuropathy, but it’s also an antidepressant. According to UpToDate, “the long-term effectiveness and safety of duloxetine for diabetic neuropathy is uncertain.” It also comes with potential side-effects including nausea, sleepiness, dizziness, decreased appetite, and constipation.
Pregabalin: Also approved by the FDA specifically for use in treating diabetic neuropathy, this drug is similar to gabapentin as it was originally intended as an anti-seizure medication. Potential side-effects, however, are a bit broader, including dizziness, sleepiness, confusion, swelling in ankles and feet, and weight gain. This drug can also be addictive, making it a more careful decision to start taking compared to gabapentin.
Tricyclic Anti-depressants: Often used to treat chronic pain, this type of antidepressant may also be known under the names amitriptyline, nortriptyline, and desipramine. Unlike SSRI antidepressants (which have not demonstrated any benefits for nerve pain), tricyclic antidepressants work by increasing levels of norepinephrine and serotonin, and they block the action of neurotransmitters (messages to and from the brain) which can include nerve pain. Taken at bedtime, the primary side-effects can include dry mouth, drowsiness, dizziness, and constipation.
Anesthetic drugs: Lidocaine can be used for treating nerve pain in some patients but it’s not the ideal, long-term treatment method. Ideal for patients who haven’t found relief with other treatment options, lidocaine is administered via a patch and is worn for up 12 hours during a 24-hour period.
Alpha-lipoic acid (ALA): This is an antioxidant medication that has demonstrated efficacy in short-term trials for relieving nerve pain in patients with diabetic retinopathy. It isn’t the first line of treatment because it hasn’t been studied for the safety of long-term use, so it’s generally only used in patients who haven’t found relief from other treatment methods. That being said, it’s already available in the USA as a dietary supplement that you can purchase without a prescription.
Narcotics (opioids): Narcotics are a highly addictive and relatively dangerous form of pain medication. It is recommended as the primary treatment for diabetic neuropathy, because of the high risk of becoming addicted and abusing the drug. While it can be used in certain patients for severe “breakthrough pain,” many healthcare professionals treating diabetic neuropathy have stopped prescribing narcotics because the risks are simply too high. And narcotics should not be considered a long-term treatment option for any condition unless absolutely necessary.
*Remember, when discussing treatment options with your healthcare team you must disclose all medications and supplements you’re currently taking. Some of the medications cannot be taken together or taken with other drugs.
Risks that come with neuropathy: infection and amputation
One of the biggest concerns when it comes to neuropathy in people with diabetes is that your loss of feeling in your feet, toes, hands, and fingers means that simple cuts, scrapes, and blisters can easily go unnoticed.
In a person with high blood sugar levels, that blister or cut can become infected. If that infection isn’t identified and treated in time, the infection can spread and put you at risk for losing a toe or your entire foot. For some, the loss could be a large percentage of your leg.
A 2018 study concluded that 50 percent of the patients with diabetes who undergo amputations each year had some degree of diabetes-related neuropathy prior to their surgery.
Tips to prevent infection and amputation
Don’t go barefoot: This puts you at risk for stepping on something sharp, cutting your skin, and not noticing it due to loss of feeling in your toes and feet.
Change your socks halfway through the day: This helps to prevent moisture. Damp feet in damp socks are an ideal place for the growth of bacteria, and it makes it harder for smaller cuts and blisters to heal. Read more about diabetes socks here.
Examine your feet every night: Before you go to bed, look closely at your feet (perhaps with a magnifying glass, if necessary) and look for any cuts or scrapes or blisters. You may need to ask a loved one to help you if you have difficulty seeing the bottom of your feet.
Trim your toes and keep them clean: Overgrown toenails and dirty feet are a wonderful environment for cuts, blisters, and bacteria. Take good care of your toenails and your feet!
Wear good shoes: If you have diabetes and neuropathy, you’d be wise to skip the stilettos and invest in good quality shoes only! Shoes that are good for your feet. Especially when exercising, make sure your shoes are the right size and the right type for the activity you’re doing. And if you’re shoes are more than a few years old, it may be time for a fresh pair. Your feet deserve it!
If you notice a blister or cut isn’t healing, don’t wait: If a blister or cut isn’t showing noticeable progress in healing within a few days of identifying it, call your doctor immediately. Any signs of infection, like puss, pain, redness, or swelling should warrant a call or even a trip to the urgent care clinic. Don’t wait.
Improve your blood sugar: Last but not least, the healthier your blood sugar levels are, the less likely a small cut will turn into a devastating infection. Excess sugar in the blood is the perfect ingredient for an infection. And consistent excess sugar in your bloodstream makes it very hard for a simple blister to heal.
Exercising with neuropathy
Last, but not least, it needs to be said that neuropathy doesn’t and shouldn’t stop you from exercising.
Getting up and being active on a regular basis is a critical part of caring for the parts of your body affected by neuropathy.
Regular exercise will help you manage, prevent, and for some, reverse your neuropathy in several ways:
- It increases blood flow which helps get fresh blood and oxygen to your toes and fingers.
- It can lower insulin resistance over time.
- It will lower blood sugar levels during exercise and over time.
- It keeps your heart healthy and reduces your risk of cardiovascular disease.
- It’s exercise! It’s good for every part of your body — especially as a person with diabetes.
But exercising with chronic pain, numbness and burning in your feet is easier said than done.
Here are a few tips for staying active despite neuropathy. Be sure to talk to your healthcare team about the right types of exercise for your specific needs as a patient with neuropathy.
Choose aerobic exercises that are low-impact or off your feet
Swimming, rowing, stationary bike, tai chi, qi-gong, and water aerobics are all great examples of getting your body moving and your blood flowing without a great deal of impact on the soles of your feet. They also don’t put you at risk for falling due to a loss of balance or muscle strength.
For some, walking may be a great aerobic exercise depending on the condition of your feet, but make sure you have good shoes and socks for the occasion to prevent blisters. And if you have injuries on your feet that are still currently healing, your doctor will likely advise you to avoid exercising on your feet altogether.
Take advantage of strength-training machines
Most gyms have strength-training or resistance-training machines that you can sit or stand at and engage nearly every muscle in your body as you make your way through the series of machines. These are great for people with diabetes and neuropathy because strength-training helps lower blood sugar levels and insulin resistance, but it’s also very low impact and doesn’t require a great deal from the soles of your feet.
And remember, the more muscle your body has, the more calories you burn at rest. While there are strength-training exercises you can do at home, the benefits of a gym with these types of circuit machines are endless for a person with neuropathy.
Use TV time to do balance exercises & gentle stretching
Set a timer next time you sit down in front of the television. Every 5 minutes, stand-up and practice a series of balancing exercises while you watch, followed by some gentle stretching. (Here are some great balance and stretching exercises from the Foundation of Peripheral Neuropathy.)
Maintaining your body’s sense of balance is critical as you work to manage your neuropathy. Don’t let the T.V. become a distraction, use it to your advantage for the more boring activities like balance exercises and stretching!
In the end, a diagnosis of neuropathy can be very overwhelming. If you use that diagnosis to empower your decisions, you can prevent it from getting worse and improve the way it impacts your life immediately.
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