What Is Diabetic Neuropathy - and Why Does It Happen?
Diabetic neuropathy refers to nerve damage associated with diabetes.
There are several different forms of diabetic neuropathy, but the most common is distal symmetric peripheral neuropathy. This usually affects the longest nerves first, which means symptoms often begin in the toes and feet before gradually moving upwards. In some people, the hands may eventually become involved too.
Persistently elevated blood glucose (high blood sugar) is an important contributor to nerve damage, although the relationship is more complicated than simply saying that “high sugar damages nerves”. Metabolic, vascular and inflammatory processes can all contribute to changes in nerve function.
What Are the First Signs You Shouldn't Ignore?
Diabetic peripheral neuropathy does not always begin with pain.
Some people first notice unusual sensations in their feet, such as tingling or “pins and needles”, burning, numbness, reduced sensation, increased sensitivity to touch, feeling as though you are wearing socks when you are not, pain from normally comfortable sensations such as bedclothes touching your feet, or a feeling of walking on pebbles or having something stuck inside your shoe. Some people experience severe pain – this is known as painful diabetic neuropathy. Others have very little pain but progressively lose sensation – this is known as non-painful diabetic neuropathy. There are also other causes of neuropathy, and treatment is often similar, but for the purpose of this blog we are only discussing neuropathy related to diabetes.
Why Are Your Feet So Vulnerable?
The nerves supplying your feet are some of the longest nerves in the body. This makes them particularly vulnerable to the effects of long-term metabolic and vascular changes associated with diabetes. Your feet rely heavily on sensation to protect you. They carry your whole body and keep you moving. If you step on something sharp, develop a blister, burn your foot or put excessive pressure on one area, your nervous system normally sends you a warning: “Something is wrong. Move your foot.”
If neuropathy has reduced your protective sensation, that warning may be weaker - or absent. You may therefore continue walking on an injured area without realising it.
Why Can a Small Cut Become a Big Problem?
In the context of diabetes, reduced sensation is combined with factors such as pressure, poor circulation, systemic inflammation, infection or impaired wound healing, which can often make recovery from a seemingly minor injury more complicated.
A blister can become an ulcer. An ulcer can become infected. In severe cases, infection and tissue damage can threaten the foot itself.
This is why foot care is prevention, not just something to think about after a problem develops.
How Can You Check Your Feet at Home?
A simple daily foot check can help you identify problems early and keeps you safe, particularly if you no longer have normal sensation in your feet. Look for cuts or grazes, blisters, redness, swelling, cracked or unusually dry skin, changes in skin colour, areas of increased pressure, changes around the toenails, and discharge or signs of infection.
Don't forget to look between your toes and underneath your feet. If it is difficult to see the soles of your feet, use a mirror or ask someone you trust to help. If you notice a wound, ulcer, spreading redness, significant swelling, discharge, or other concerning changes, seek medical advice promptly. It is best to be overly cautious when it comes to foot care!
Can Diabetic Neuropathy Be Treated?
Yes, but the type of treatment depends on what we are trying to achieve.
There are several goals of treatment:
• Preventing or slowing further nerve damage
• Protecting the feet from injury
• Reducing pain where painful neuropathy is present
• Improving sleep and quality of life
• Maintaining activity, independence and mobility
There is no single treatment that works for everyone. A good treatment plan considers the person rather than simply treating a pain score.
Managing the pain is only one part of managing diabetic peripheral neuropathy. Importantly, your diabetes still needs to be managed appropriately by your GP, endocrinologist or other specialist physician. The Pain Collective can help with the pain and functional consequences of peripheral neuropathy, but pain treatment does not replace effective management of the underlying diabetes and will most likely be less effective if your underlying condition isn’t managed well.
Start with the Foundations
Before considering procedures, it is important to address the things that can influence both your overall health and your ability to live well with painful or non-painful neuropathy.
This includes appropriate diabetes management, physical activity, exercise and strengthening, good nutrition, smoking cessation, sleep, foot care, wearing appropriate footwear and managing cardiovascular risk factors.
These interventions do not necessarily make nerve pain disappear, but they can make an important contribution to maintaining function, independence and quality of life.
Exercise and Physical Activity
Exercise is sometimes approached cautiously when someone has painful or numb feet. But avoiding movement altogether can lead to even more difficulty with blood glucose control, loss of strength, fitness and confidence.
Exercise can improve physical function, balance, metabolic and cardiovascular health and overall wellbeing. It can also influence pain through mechanisms involving the peripheral and central nervous systems. The right type and amount of exercise depend on your symptoms, fitness, balance, foot health and other medical conditions, but in general, aerobic exercise is beneficial for people with diabetes.
Physiotherapy may be particularly helpful if you have weakness, balance problems, changes in your walking pattern or concerns about falling, while biokineticists can help develop an exercise program that contains the right kind and amount of exercise, taking your metabolic health into consideration.
Occupational Therapy
Occupational therapy can help when neuropathy starts interfering with everyday activities.
This might include looking at how you move around your home, how you manage work and daily activities, foot protection, fatigue management, falls prevention and adaptations that help you remain independent.
Sometimes the most useful treatment isn't about reducing the pain score. It is about helping you do more despite the pain.
Psychological Approaches and Self-Management
Living with persistent nerve pain can affect mood, sleep, relationships and confidence.
Recommendations for psychological approaches such as cognitive behavioural therapy and acceptance-based approaches don't mean that the pain isn’t real. It means that your practitioner is recognising that living with persistent pain is hard, and psychological interventions can help people develop skills for managing the impact of persistent pain, particularly when pain has begun to affect sleep, activity or quality of life.
These approaches can form part of a broader pain-management programme alongside physical and medical treatments.
Medication for Nerve Pain
There are several medication options for painful diabetic peripheral neuropathy, including pregabalin and gabapentin, duloxetine and other serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants in appropriate patients, and certain sodium-channel-blocking medicines. Don’t worry about the complicated sounding names – all these medications have one thing in common: They act on the nerves themselves or on how the nervous system processes information coming from the nerves. Typically, simple analgesics like paracetamol don’t work for nerve pain.
No single medication is best for everyone. The American Academy of Neurology recommends offering medicines from effective classes and considering how people respond in terms of side effects, other medical conditions, cost and patient preference.
Some people experience dizziness, sedation, swelling, nausea or changes in blood pressure in response to these ‘nerve medications. Side effects mostly settle within a few weeks but may be difficult to tolerate. Opioids are generally not recommended as routine treatment for painful diabetic neuropathy because their long-term harms can outweigh their benefits.
What About Neuromodulation?
Neuromodulation is a broad term for treatments that use electrical, magnetic or other forms of stimulation to influence the way the nervous system processes sensory information.
There is growing interest in neuromodulation for painful diabetic peripheral neuropathy, particularly when conventional treatments have not provided enough relief.
But neuromodulation is not one treatment. Some approaches are non-invasive and relatively simple to try. Others involve injections or temporary procedures. Some involve implanting a device. The evidence is different for each.
Non-invasive Neuromodulation
One of the simplest forms is transcutaneous electrical nerve stimulation (TENS). TENS uses electrodes placed on the skin to deliver electrical stimulation. It does not involve an injection or an implanted device and is generally well tolerated.
There is some evidence that TENS can reduce pain in people with diabetic peripheral neuropathy. Recent systematic reviews and network meta-analyses have found encouraging results, but the evidence base remains relatively small, and studies differ in methods and follow-up.
Other non-invasive approaches, including repetitive transcranial magnetic stimulation, transcranial direct current stimulation, pulsed electromagnetic field therapies and frequency-modulated electrical stimulation—have also been studied. Some of these modalities have produced encouraging results in individual trials. However, the evidence is inconsistent. These treatments should generally be regarded as possible adjuncts rather than replacements for conventional treatment.
What About Procedures in theatre?
Some interventional procedures have also been investigated for painful diabetic neuropathy. The evidence here is more limited than many people might expect.
The sympathetic nervous system (the fight-or-flight system) can contribute to pain in some people. A lumbar sympathetic block might be useful in selected patients, if there is evidence that sympathetic mechanisms are contributing to a person’s pain.
Pulsed radiofrequency (PRF) is another modality that may be useful. PRF delivers short bursts of energy with the intention of modifying nerve function while limiting tissue damage.
PRF has been investigated for painful diabetic neuropathy, particularly when directed at the lumbar sympathetic chain. There are reports of meaningful pain relief lasting several months in some patients. However, the evidence is largely from small observational studies and uncontrolled series rather than large, high-quality randomised trials.
A 2024 review therefore describes sympathetic-chain radio frequency as something that may be considered in cases where pain is resistant to other treatments and where there is evidence that the fight-or-flight system is contributing to someone’s pain.
Other minimally invasive treatments, including intravenous lidocaine, botulinum toxin injections and various peripheral nerve interventions have also been investigated. Some have produced encouraging results in small studies, but none currently has the same depth of evidence as the better-established lifestyle interventions, pharmacological treatments or spinal cord stimulation.
What About Spinal Cord Stimulation?
While not being offered as a treatment by the Pain Collective, Spinal cord stimulation (SCS) is currently the most extensively studied advanced neuromodulation treatment for painful diabetic peripheral neuropathy.
SCS involves placing electrodes in the epidural space near the spinal cord. The electrodes deliver electrical stimulation that changes the way pain signals are processed within the nervous system.
It is intended to reduce pain. It does not repair the underlying nerve damage, cure diabetes or replace treatment aimed at controlling the underlying metabolic disease.
SCS Is Not a Treatment That Everyone Can Simply Access
SCS involves an implanted medical device, placed during a procedure in theatre and requires lifelong, ongoing specialist care. It is therefore considerably more resource-intensive and expensive than treatments such as exercise, medication, TENS or rehabilitation. Access and funding can be significant practical barriers, and for many people living with diabetes SCS may simply not be a realistic option.
That should not mean that they have no options. There are many other ways of managing painful diabetic neuropathy, and a good pain service should help people identify treatments that are appropriate not only clinically, but also practically and financially.
Where Does This Leave You?
There is no single treatment that works for everyone with painful diabetic peripheral neuropathy. The priority remains good diabetes management and prevention of further complications.
Non-pharmacological approaches such as exercise, physiotherapy, occupational therapy, foot care, education and psychological strategies can help you remain active and independent. Medications are typically part of the treatment plan and can reduce neuropathic pain for some people, although benefits and side effects vary.
Non-invasive neuromodulation, particularly TENS, may be useful for some people and can be practical and relatively affordable. Interventional procedures, including sympathetic procedures and PRF, may have a role in carefully selected people, but the evidence is considerably less certain.
Spinal cord stimulation has the strongest evidence among advanced neuromodulation treatments, but it is an invasive, expensive treatment that is generally reserved for people with severe, refractory pain and is not readily accessible or affordable for everyone.
Good pain care isn't about finding the most advanced treatment available. It is about finding the treatment, or combination of treatments, that makes sense for you, based on your symptoms, health, goals, preferences, the evidence and what is realistically accessible.
Whatever pain treatment you receive, it should sit alongside, not instead of, appropriate management of your diabetes.
Your GP or specialist physician remains responsible for helping you manage the underlying diabetes and reduce your risk of complications.
The Pain Collective can help with the pain and functional consequences of peripheral neuropathy, working alongside the rest of your healthcare team to help you remain active, independent and able to participate in the things that matter to you.
The Bottom Line
Start with the foundations: look after your diabetes, protect your feet, stay active and address the factors that affect your ability to live well. If nerve pain persists, medication and rehabilitation can help.
If pain remains difficult to control, selected interventional treatments may be appropriate, but the evidence varies considerably between procedures, and it is important that you discuss all the options with your treating team.