Peripheral Neuropathy

When the nerves themselves are the problem

Peripheral neuropathy means damage to the nerves outside the brain and spinal cord — the nerves that carry sensation, motor signals, and autonomic function to your arms, legs, hands, and feet. It's more common than most people realize, and it affects millions of adults, particularly those over 50.

The symptoms depend on which types of nerve fibers are involved. Sensory neuropathy causes numbness, tingling, burning, or a "pins and needles" feeling — usually starting in the feet and working upward in a stocking-glove pattern. Motor neuropathy causes weakness. Autonomic neuropathy can affect blood pressure, digestion, and sweating.

Why it matters

Peripheral neuropathy is not a diagnosis — it's a finding. The question is always: why are the nerves damaged? Identifying the cause determines the treatment and the prognosis.

Diabetes and prediabetes. The most common cause by far. Chronically elevated blood sugar damages small blood vessels that supply the nerves. Diabetic neuropathy typically starts in the feet as a gradual onset of numbness and burning. What many people don't know is that prediabetes — blood sugar levels that are elevated but not yet in the diabetic range — can cause neuropathy too.

Vitamin deficiencies. B12 deficiency is a well-known cause. B6 toxicity (from excessive supplementation) can paradoxically cause neuropathy as well. Folate, thiamine, and copper deficiencies are less common but worth checking.

Alcohol. Chronic alcohol use damages nerves both directly and through associated nutritional deficiencies.

Autoimmune and inflammatory conditions. Conditions like chronic inflammatory demyelinating polyneuropathy (CIDP) and vasculitis can attack the nerve sheath or blood supply. These are less common but important to identify because they're treatable.

Medications. Certain chemotherapy agents, some antibiotics (metronidazole, nitrofurantoin), and statins in rare cases can all cause neuropathy.

Idiopathic. In roughly a quarter of cases, no definitive cause is found even after thorough workup. This is frustrating but important to document — it changes the monitoring and management approach.

How we diagnose it

The exam tells us the pattern — which areas are affected, which nerve fiber types are involved, and whether it's getting better or worse. Nerve conduction studies and EMG confirm the diagnosis, characterize the type of neuropathy (axonal vs demyelinating, length-dependent vs multifocal), and help narrow the differential.

This distinction matters. An axonal, length-dependent sensory neuropathy in a patient with diabetes points in one direction. A demyelinating, multifocal neuropathy in a young patient points in a very different direction and may warrant aggressive treatment.

Lab work fills in the rest: hemoglobin A1c, B12, metabolic panel, thyroid function, and potentially more specialized tests depending on the clinical picture.

How we treat it

The most important step is treating the underlying cause when one is found. Optimizing blood sugar control in diabetic neuropathy can slow progression and sometimes allow nerve recovery. Repleting B12 in deficiency neuropathy can reverse symptoms if caught early enough.

Symptom management is the other pillar. Neuropathic pain responds to specific medications — gabapentin, pregabalin, duloxetine, and topical agents like capsaicin and lidocaine patches. These work on the nerve signaling pathways that generate burning and tingling. Standard painkillers like ibuprofen and acetaminophen are generally ineffective for nerve pain.

OMM can address the musculoskeletal consequences of neuropathy. When sensation is reduced in the feet, gait changes, balance worsens, and compensatory patterns develop in the ankles, knees, hips, and back. Treating these secondary dysfunctions can significantly improve function and comfort.

Fall prevention is critical. Reduced sensation in the feet is a major risk factor for falls. Balance training, appropriate footwear, and home safety modifications are not glamorous interventions, but they prevent serious injury.

When to seek care

If you have persistent numbness or tingling in your hands or feet, burning pain that doesn't respond to typical pain medication, or if you're noticing changes in balance or coordination, you should be evaluated. Neuropathy that's caught early — especially from reversible causes like B12 deficiency or prediabetes — has a much better prognosis than neuropathy that's been progressing for years.

What you can do right now

Check your feet. If you have reduced sensation, inspect your feet daily for cuts, blisters, or sores you might not feel. Foot injuries in the setting of neuropathy can become serious quickly.

Stay active. Exercise improves blood flow to peripheral nerves and has been shown to reduce neuropathic pain. Walking, cycling, and swimming are all good options. Start gently and build gradually.

Know your numbers. If you haven't had a hemoglobin A1c or B12 level checked recently, ask your primary care doctor. Catching prediabetes early can prevent neuropathy from ever developing.