Peripheral neuropathy
Peripheral neuropathy is damage to the nerves running from the spinal cord to the arms, legs and internal organs.
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On this page
- What damaged nerves feel like
- What damages nerves most often
- Similar symptoms with something else behind them
- How the cause is looked for
- Signs that cannot wait
- The main treatment is dealing with the cause
- Medicines for nerve pain and how to take them
- When nerves upset blood pressure, the stomach and the bladder
- Feet that have stopped feeling
- Online consultation
Medicines commonly prescribed for Peripheral neuropathy
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: CAPSULE, 30 mgActive substance: duloxetineManufacturer: Viatris Pharmaceuticals S.L.U.Prescription requiredDosage form: CAPSULE, 90 mgActive substance: duloxetineManufacturer: Neuraxpharm Spain S.L.Prescription requiredDosage form: CAPSULE, 30 mgActive substance: duloxetineManufacturer: Almus Farmaceutica S.A.U.Prescription required
Peripheral neuropathy is damage to the nerves running from the spinal cord to the arms, legs and internal organs. The word describes not a single illness but an outcome: a fibre stops carrying signals properly, and the person feels numbness, burning, tingling or weakness. There are more than a hundred causes, and almost everything depends on which one is found — whether the damage can be reversed, and what will actually ease the pain. The main work here is therefore not choosing a painkiller but finding the cause. What follows is how neuropathy shows itself, what lies behind it, how it is confirmed, what settles the pain and when delay is not an option.
What damaged nerves feel like
The picture depends on which fibres have been affected, and they are usually affected together.
- Sensory fibres. Numbness, tingling, a feeling of cotton wool or sand underfoot, burning, shooting jolts like an electric shock. The sense of pain and temperature is often blunted: a pebble in the shoe goes unnoticed and hot water does not feel hot. The opposite also happens, with the touch of a bedsheet becoming painful.
- Motor fibres. Cramps, twitching, weakness, wasting of the calf and hand muscles. The foot stops lifting as you step and the toe catches on the floor.
- Autonomic fibres. Dizziness on standing, sweating in the wrong place at the wrong time, dry skin on the feet, heaviness after meals, constipation or night-time diarrhoea, difficulty emptying the bladder.
The commonest form develops in a recognisable order: the longest nerves suffer first, so it begins in the toes and creeps upward "in a stocking pattern"; once it reaches mid-calf, the fingertips join in "in a glove pattern". That symmetry and the upward march are an important clue. If instead one hand or one foot goes numb, a single nerve has been damaged and the cause is looked for elsewhere.
What damages nerves most often
A cause is identified in about three quarters of people; in the rest it is called idiopathic, and that is a recognised end point of the assessment rather than an evasion.
- Diabetes is the leading cause. Nerves suffer not only in established diabetes but in prediabetes too, while the fasting glucose is still almost normal; that is why the glycated haemoglobin is also checked.
- Alcohol, both by acting on the nerve directly and through a shortage of B vitamins.
- Vitamin B12 deficiency. One of the few causes that can be put right completely if caught in time; advanced damage recovers poorly. Stores are run down by a strict vegan diet without supplements, by stomach disease and surgery, and by long-term use of metformin and acid-lowering medicines.
- Medicines. Chemotherapy, amiodarone, phenytoin, isoniazid, long courses of metronidazole or nitrofurantoin. Separately, too much vitamin B6: in large doses it does not heal nerves but damages them, and such doses are easily reached through "nerve support" supplement blends.
- Thyroid, kidney and liver disease, and infections too — shingles, Lyme disease, HIV, hepatitis.
- Autoimmune conditions — Sjögren's syndrome, lupus, rheumatoid arthritis, coeliac disease, vasculitis, and chronic inflammatory demyelinating polyneuropathy, which matters because it responds well to treatment.
- An abnormal protein in the blood, in monoclonal gammopathy, myeloma and amyloidosis. This is considered when numbness comes together with weight loss, bone pain or abnormal kidney results.
- Inherited neuropathies, such as Charcot-Marie-Tooth disease. Clues: symptoms since childhood, a very high arch, similar-looking feet in relatives.
- Toxins — lead, mercury, arsenic, solvents — and injury to a nerve.
Similar symptoms with something else behind them
Numbness and leg pain do not come only from the peripheral nerves, and that has to be sorted out before any treatment is started.
- A compressed nerve root in the spine. The pain and numbness run down the leg in a band, start from the lower back, change with position and with coughing, and usually take one leg rather than both.
- Narrowing of the spinal canal. Numbness and weakness appear on walking and clear on sitting down or leaning forward.
- A trapped individual nerve. Carpal tunnel syndrome numbs the first three and a half fingers, wakes you at night and eases when the hand is shaken; a trapped ulnar nerve takes the little finger and half the ring finger.
- Arterial disease of the legs. Cold feet and non-healing wounds again, but with calf pain on walking that clears on stopping, and no pulse to be felt in the foot.
- A problem at the level of the spinal cord. A sharp sensory level on the trunk, stiffness and brisk reflexes in the legs and disturbed bladder control are warning signs and call for urgent assessment and an MRI scan.
- Restless legs syndrome. The unpleasant sensations come at rest and in the evening and are relieved instantly by moving; in neuropathy movement does not work like that.
How the cause is looked for
Examination counts for more here than it may seem: the doctor tests sensation with a monofilament and a tuning fork, assesses reflexes, strength, gait and balance, inspects the feet and the shape of the arch, and feels for foot pulses.
- Blood tests — glucose and glycated haemoglobin, vitamin B12, thyroid, kidney and liver function, a full blood count, inflammatory markers and serum protein electrophoresis. This panel covers most of the correctable causes.
- Nerve conduction studies with electromyography — a test of conduction along the nerves together with an assessment of the muscles. It shows whether there is damage, where it is and what type it is: whether the nerve's covering or the fibre itself is affected.
- Where indicated — an MRI of the spine if the picture points to a root or the cord; examination of the spinal fluid where an inflammatory neuropathy is suspected; a skin biopsy to assess the fine fibres; genetic testing.
An important caveat: a normal nerve conduction study does not rule the diagnosis out. That test sees only the large fibres. There is such a thing as small-fibre neuropathy, in which the person is troubled by burning and tender skin while the machine reads normal — and it is precisely in that situation that people are most often told everything is fine. If the symptoms are typical, the assessment continues by other routes.
Signs that cannot wait
Most neuropathies develop over months and years. A rapid onset is a different story altogether.
Call an ambulance — in Spain, Italy, Portugal, Poland and Ukraine the single number is 112 — if:
- weakness in the legs has built up over hours or days and is climbing higher, taking in the thighs, the trunk and the arms;
- breathing has become difficult, there is not enough air lying flat, or speaking in long sentences is hard;
- choking, difficulty swallowing, slurred speech or weakness of the facial muscles appear;
- the area between the legs goes numb and urine is retained or leaks, together with weakness in the legs.
Rapidly rising, ascending weakness is Guillain-Barré syndrome, which often begins one to three weeks after a gut infection or a cold. It is treatable, and the sooner treatment starts the better; the danger lies in the muscles of breathing and swallowing weakening. Numbness between the legs with disturbed bladder control points to compression of the nerve roots at the very bottom of the spine and calls for surgery within hours.
The same day, though without an ambulance, see a doctor if an ulcer or a non-healing wound has appeared on the foot, and if the numbness came on during chemotherapy or after starting a new medicine.
The main treatment is dealing with the cause
Whatever can be corrected is corrected first: blood sugar control, stopping alcohol, replacing B12, adjusting the thyroid, withdrawing or swapping the responsible medicine, treating the autoimmune disease. That is the only way to halt the damage; everything else works on the symptom. Nerve recovery is slow, a matter of months, and it is recognised more by the symptoms ceasing to progress than by rapid relief.
Inflammatory neuropathies are treated directly, with drugs that damp down the immune system and with immunoglobulin infusions. Inherited forms cannot be removed, but the diagnosis still earns its place there: it settles the outlook and allows orthotic support for the foot to be arranged in good time.
Medicines for nerve pain and how to take them
Ordinary painkillers are as a rule useless against nerve pain: neither paracetamol nor anti-inflammatories act on that mechanism, and the latter carry their own risks for the stomach, the kidneys and blood pressure.
- What does work are medicines from the anti-epileptic and antidepressant groups. Being prescribed an antidepressant does not mean the pain is thought to be imaginary: at low doses these drugs alter the transmission of the pain signal.
- They are started at a low dose and increased gradually, and the effect is not judged before several weeks have passed. Dropping the drug after three days on the grounds that it "isn't working" is the commonest mistake.
- They must not be stopped abruptly. The dose is reduced to a plan: sudden withdrawal brings anxiety, insomnia, nausea and sweating, and the pain returns worse than before.
- Drowsiness, dizziness and swollen ankles are usual in the first weeks. While they last, do not drive; alcohol makes them markedly worse.
- Topical treatments — capsaicin cream or patch, a local anaesthetic plaster — suit pain confined to one area. Capsaicin stings for the first few days and is not applied to broken skin.
- Opioid painkillers work poorly for nerve pain and are prescribed only briefly. Tell the doctor if you are already on an antidepressant: the combination with some of them is dangerous.
- Supplements such as alpha-lipoic acid and benfotiamine are poorly studied. Vitamin B12 is for those with a proven deficiency, not for everybody.
Alongside medicines, what is easy to undervalue also helps: exercise within your limits, decent sleep, losing weight, spreading effort across the day and, in persistent pain, psychological approaches to managing it.
When nerves upset blood pressure, the stomach and the bladder
Autonomic fibres run what happens without our involvement, and their failures are seldom connected with neuropathy.
- Blood pressure dropping on standing. It helps to get up slowly and in two stages, drink enough fluid, wear compression stockings and raise the head of the bed; sometimes the doctor adds medication. Do tell them about every blood pressure medicine you take — some may need revisiting.
- Stomach and bowel. Heaviness, bloating and nausea after meals from slow stomach emptying, alternating constipation and diarrhoea, a feeling that the bladder has not emptied, and repeated urinary infections. Small frequent meals and less fat help; medicines are prescribed by a doctor and for a limited time.
- The heart. In marked autonomic neuropathy the pulse stops speeding up normally with exertion, and a heart attack can pass off without the usual chest pain — with only breathlessness, weakness or sweating. This is worth knowing, and such episodes should not be waved away.
Balance is a subject of its own. When the feet sense the ground poorly, the risk of falls rises, particularly in the dark. A night light on the way to the bathroom helps, as do firm indoor shoes rather than backless slippers, cables and rugs cleared away, a grab rail in the bathroom, and balance work with a physiotherapist.
Feet that have stopped feeling
Loss of sensation is more dangerous than pain: pain gets in the way of living, but numbness lets a wound go unnoticed. Checking the feet takes five minutes a day and remains the single most effective measure against ulceration and amputation.
- Look your feet over every evening, heels and the spaces between the toes included; a mirror helps for the awkward parts.
- Run a hand inside a shoe before putting it on: a pebble or a folded insole is easily missed.
- Test water with your hand or elbow, never with your foot. Do not warm your feet with a hot water bottle or by a heater — that is how burns happen that are only discovered when the wound appears.
- Wash in warm water, dry carefully between the toes and soften dry skin with cream, keeping it out of the spaces between the toes. Cut nails straight across, and do not pare hard skin yourself — that is a job for a podiatrist.
- Shoes soft, well fitting, without inner seams; do not walk barefoot even indoors.
- Show a doctor any wound, darkened patch, crack or weeping area straight away rather than a week later.
Online consultation
Rapidly increasing weakness, or difficulty breathing or swallowing, is not for an online conversation — that is an ambulance call. Slowly moving neuropathy, on the other hand, fits almost entirely into a discussion from home. A doctor can help you tell whether your sensations look like a polyneuropathy or point to a nerve root, the carpal tunnel or the blood vessels; say which tests to ask for first so that a correctable cause is not missed — B12 deficiency, the thyroid, prediabetes, an abnormal protein; go through the nerve conduction report, including the case where it is normal and the burning remains; explain how to take the medicines for nerve pain and why they are not stopped all at once; review your medicines and supplements with you for the ones that damage nerves in their own right; teach you to check your feet and put together measures against falls. A reason of its own to write in: a wound on the foot that will not heal, and numbness that has climbed noticeably higher over a few weeks.
This material is for information only and does not replace medical advice.
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