Nerve damage in the feet

What it is

Peripheral neuropathy damages the longest nerves first, which is why it starts in the feet and progresses upward in a stocking distribution. Small fibres carrying pain and temperature go first, producing burning and numbness; larger fibres carrying position sense follow, and that is what takes the balance.

The balance consequence is the one that matters most practically. Vision can partly compensate for lost foot sensation, which is why standing in the dark or closing the eyes in the shower is so much harder. It is also why the fall risk is high and why balance training - not just protecting the feet - is a central part of managing it.

What it feels like

• Numbness, tingling or burning in the feet, usually both sides and symmetrical
• A sensation of walking on cotton wool or on a lumpy sock
• Worse at night, particularly the burning
• Markedly worse balance in the dark or with eyes closed
• Not noticing a stone in the shoe, a blister or a cut - which is the dangerous part

What causes it

Most people have more than one of these at once, and they feed each other. Read the list looking for the two or three that sound like your week rather than for the one true answer — the ones that describe you are the ones worth acting on.

Diabetes

The commonest cause by a wide margin. High glucose damages the small blood vessels supplying nerves and the nerves themselves, and the risk rises with duration and with how well glucose has been controlled.

Chemotherapy

Platinum drugs, taxanes and vinca alkaloids all cause a dose-dependent neuropathy. It can persist for years after treatment and is a major quality-of-life issue for cancer survivors.

Alcohol

Directly toxic to nerves and additionally causes nutritional deficiency. Alcohol-related neuropathy is common and improves substantially with abstinence.

Vitamin B12 deficiency

A treatable cause that is frequently missed. Metformin, long-term acid suppression, vegan diets and pernicious anaemia are common routes to it, and correcting it can halt or reverse the damage.

Loss of intrinsic foot muscle

The small muscles inside the foot waste as their nerve supply fails. That produces toe clawing, changed pressure distribution and a further loss of the stability the foot provided.

Kidney disease

Uraemic neuropathy is common in advanced chronic kidney disease and improves with dialysis or transplantation.

Thyroid disease and other systemic conditions

Hypothyroidism, some autoimmune diseases and inflammatory conditions all cause neuropathy, and several are treatable.

Inherited neuropathies

Charcot-Marie-Tooth disease and related conditions produce a slowly progressive neuropathy, often with high arches and clawed toes, usually with a family history.

Idiopathic

In a substantial proportion no cause is found despite investigation. That is frustrating and it does not change the management of the balance and foot protection.

Not looking for a reversible cause

B12, thyroid, glucose and alcohol are all common, all testable and all treatable. Accepting a neuropathy without excluding them is a genuine missed opportunity.

Who tends to get it

• Anyone with diabetes, particularly of long duration
• People who have had chemotherapy
• Anyone drinking heavily over years
• People on metformin or long-term acid suppression, through B12 depletion
• Anyone with chronic kidney disease or a family history of neuropathy

What makes it worse, and what settles it

The qFIT routine for this

Ready-made routineMovement for Neurological Conditions

qFIT already has this one built. It runs massage first, then stretching, then strength — the order that works on a body that is already sore — and every activity in it carries the reason it is there.

The button below opens your Checklist with this routine already selected, so instead of your whole list you land on just its Categories, Targets and Exercises, each with its checkbox, ready to tick as you work through them.

Have more than one problem? Tick yours under My Problems on My Profile and your Checklist's Routine list gains Recommended for my problems — every routine for the problems you picked, merged into one. Your picks stay private; that filter is the only thing they feed.

Get it checked if…

Any foot ulcer, wound or color change in a person with neuropathy is urgent - they cannot feel damage; never use heat or a massage gun on numb feet

And whatever the body part: chest pain or unusual breathlessness on exertion; a fever alongside the pain; unexplained weight loss; pain that is constant and unrelated to how you move; new numbness, weakness or loss of bladder or bowel control; or one calf that is swollen, warm and painful. Any of those, stop and get assessed.

How it usually goes

Nerve damage is often permanent, but progression can frequently be slowed by treating the cause, and balance and strength improve with training regardless of whether the sensation returns. Exercise has evidence for slowing progression in diabetic neuropathy specifically. The most important practical goals are preventing falls and preventing foot ulcers, both of which are achievable. Any new foot wound, redness or swelling in someone with neuropathy needs same-day attention rather than watching.

Prevalence basis: Neurology and diabetes cohorts

Others the same routine covers

These share the Movement for Neurological Conditions routine, so the work is the same. If one of them also sounds like you, that is a reason to expect more from it, not less.

This is general information, not a diagnosis, and it cannot examine you. If it matches you, use it to ask better questions of a clinician rather than to replace one.