Diabetic Neuropathy

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What Is Diabetic Neuropathy?

Diabetic neuropathy is nerve damage that is caused by diabetes.

Nerves are bundles of special tissues that carry signals between your brain and other parts of your body. The signals

  • send information about how things feel
  • move your body parts
  • control body functions such as digestion

What are the different types of diabetic neuropathy?

Types of diabetic neuropathy include the following:

Peripheral neuropathy

Peripheral neuropathy is nerve damage that typically affects the feet and legs and sometimes affects the hands and arms.

Autonomic neuropathy

Autonomic neuropathy is damage to nerves that control your internal organs. Autonomic neuropathy can lead to problems with your heart rate and blood pressure, digestive system, bladder, sex organs, sweat glands, eyes, and ability to sense hypoglycemia.

Focal neuropathies

Focal neuropathies are conditions in which you typically have damage to single nerves, most often in your hand, head, torso, and leg.

Proximal neuropathy

Proximal neuropathy is a rare and disabling type of nerve damage in your hip, buttock, or thigh. This type of nerve damage typically affects one side of your body and may rarely spread to the other side. Proximal neuropathy often causes severe pain and may lead to significant weight loss.

Who is most likely to get diabetic neuropathy?

If you have diabetes, your chance of developing nerve damage caused by diabetes increases the older you get and the longer you have diabetes. Managing your diabetes is an important part of preventing health problems such as diabetic neuropathy.

Woman checking blood glucose.
Managing your diabetes is an important part of preventing health problems such as diabetic neuropathy.

You are also more likely to develop nerve damage if you have diabetes and

Research also suggests that certain genes may make people more likely to develop diabetic neuropathy.

What causes diabetic neuropathy?

Over time, high blood glucose levels, also called blood sugar, and high levels of fats, such as triglycerides, in the blood from diabetes can damage your nerves. High blood glucose levels can also damage the small blood vessels that nourish your nerves with oxygen and nutrients. Without enough oxygen and nutrients, your nerves cannot function well.

How common is diabetic neuropathy?

Although different types of diabetic neuropathy can affect people who have diabetes, research suggests that up to one-half of people with diabetes have peripheral neuropathy.1,2 More than 30 percent of people with diabetes have autonomic neuropathy.2

The most common type of focal neuropathy is carpal tunnel syndrome, in which a nerve in your wrist is compressed. Although less than 10 percent of people with diabetes feel symptoms of carpal tunnel syndrome, about 25 percent of people with diabetes have some nerve compression at the wrist.2

Other focal neuropathies and proximal neuropathy are less common.

What are the symptoms of diabetic neuropathy?

Your symptoms depend on which type of diabetic neuropathy you have. In peripheral neuropathy, some people may have a loss of sensation in their feet, while others may have burning or shooting pain in their lower legs. Most nerve damage develops over many years, and some people may not notice symptoms of mild nerve damage for a long time. In some people, severe pain begins suddenly.

What problems does diabetic neuropathy cause?

Peripheral neuropathy can lead to foot complications, such as sores, ulcers, and infections, because nerve damage can make you lose feeling in your feet. As a result, you may not notice that your shoes are causing a sore or that you have injured your feet. Nerve damage can also cause problems with balance and coordination, leading to falls and fractures.

These problems may make it difficult for you to get around easily, causing you to lose some of your independence. In some people with diabetes, nerve damage causes chronic pain, which can lead to anxiety and depression.

Autonomic neuropathy can cause problems with how your organs work, including problems with your heart rate and blood pressure, digestion, urination, and ability to sense when you have low blood glucose.

How can I prevent diabetic neuropathy?

To prevent diabetic neuropathy, it is important to manage your diabetes by managing your blood glucose, blood pressure, and cholesterol levels.

You should also take the following steps to help prevent diabetes-related nerve damage:

  • be physically active
  • follow your diabetes meal plan
  • get help to quit smoking
  • limit alcoholic drinks to no more than one drink per day for women and no more than two drinks per day for men
  • take any diabetes medicines and other medicines your doctor prescribes
Man breaking a cigarette in half.
To help prevent diabetes-related nerve damage, get help to quit smoking.

How can I prevent diabetic neuropathy from getting worse?

If you have diabetic neuropathy, you should manage your diabetes, which means managing your blood glucose, blood pressure, cholesterol levels, and weight to keep nerve damage from getting worse.

Foot care is very important for all people with diabetes, and it’s even more important if you have peripheral neuropathy. Check your feet for problems every day, and take good care of your feet. See your doctor for a neurological exam and a foot exam at least once a year—more often if you have foot problems.

References

Peripheral Neuropathy

What is peripheral neuropathy?

Peripheral neuropathy is a type of nerve damage that typically affects the feet and legs and sometimes affects the hands and arms.

This type of neuropathy is very common. Up to one-half of people with diabetes have peripheral neuropathy.1,2

What causes peripheral neuropathy?

Over time, high blood glucose, also called blood sugar, and high levels of fats, such as triglycerides, in the blood from diabetes can damage your nerves and the small blood vessels that nourish your nerves, leading to peripheral neuropathy.

What are the symptoms of peripheral neuropathy?

If you have peripheral neuropathy, your feet, legs, hands, or arms may feel

  • burning
  • tingling, like “pins and needles”
  • numb
  • painful
  • weak

You may feel extreme pain in your feet, legs, hands, and arms, even when they are touched lightly. You may also have problems sensing pain or temperature in these parts of your body.

Woman massaging her foot.
If you have peripheral neuropathy, you may feel burning or tingling, like “pins and needles,” in your feet.

Symptoms are often worse at night. Most of the time, you will have symptoms on both sides of your body. However, you may have symptoms only on one side.

If you have peripheral neuropathy, you might experience:

  • changes in the way you walk
  • loss of balance, which could make you fall more often
  • loss of muscle tone in your hands and feet
  • pain when you walk
  • problems sensing movement or position
  • swollen feet

What problems does peripheral neuropathy cause?

Peripheral neuropathy can cause foot problems that lead to blisters and sores. If peripheral neuropathy causes you to lose feeling in your feet, you may not notice pressure or injuries that lead to blisters and sores. Diabetes can make these wounds difficult to heal and increase the chance of infections. These sores and infections can lead to the loss of a toe, foot, or part of your leg. Finding and treating foot problems early can lower the chances that you will develop serious infections.

This type of diabetes-related nerve damage can also cause changes to the shape of your feet and toes. A rare condition that can occur in some people with diabetes is Charcot’s foot, a problem in which the bones and tissue in your foot are damaged.

Peripheral neuropathy can make you more likely to lose your balance and fall, which can increase your chance of fractures and other injuries. The chronic pain of peripheral neuropathy can also lead to grief, anxiety, and depression.

How do doctors diagnose peripheral neuropathy?

Doctors diagnose peripheral neuropathy based on your symptoms, family and medical history, a physical exam, and tests. A physical exam will include a neurological exam and a foot exam.

Examination for neuropathy

If you have diabetes, you should get a thorough exam to test how you feel in your feet and legs at least once a year. During this exam, your doctor will look at your feet for signs of problems and check the blood flow and feeling, or sensation, in your feet by

  • placing a tuning fork against your great toes and higher on your feet to check whether you can feel vibration
  • touching each foot and some toes with a nylon strand to see if you can feel it—a procedure called a monofilament test
  • reviewing your gait, or the patterns you make when you walk
  • testing your balance

Your doctor may also check if you can feel temperature changes in your feet.

What tests do doctors use to diagnose peripheral neuropathy?

Your doctor may perform tests to rule out other causes of nerve damage, such as a blood test to check for thyroid problems, kidney disease, or low vitamin B12 levels. If low B12 levels are found, your doctor will do additional tests to determine the cause. Metformin use is among several causes of low vitamin B12 levels. If B12 deficiency is due to metformin, metformin can be continued with B12 supplementation.

How can I prevent the problems caused by peripheral neuropathy?

You can prevent the problems caused by peripheral neuropathy by managing your diabetes, which means managing your blood glucose, blood pressure, and cholesterol. Staying close to your goal numbers can keep nerve damage from getting worse.

If you have diabetes, check your feet for problems every day and take good care of your feet. If you notice any foot problems, call or see your doctor right away.

Remove your socks and shoes in the exam room to remind your doctor to check your feet at every office visit. See your doctor for a foot exam at least once a year—more often if you have foot problems. Your doctor may send you to a podiatrist.

How do doctors treat peripheral neuropathy?

Doctors may prescribe medicine and other treatments for pain.

Medicines for nerve pain

Your doctor may prescribe medicines to help with pain, such as certain types of

Although these medicines can help with the pain, they do not change the nerve damage. Therefore, if there is no improvement with a medicine to treat pain, there is no benefit to continuing to take it and another medication may be tried.

All medicines have side effects. Ask your doctor about the side effects of any medicines you take. Doctors don’t recommend some medicines for older adults or for people with other health problems, such as heart disease.

Some doctors recommend avoiding over-the-counter pain medicines, such as acetaminophen and ibuprofen. These medicines may not work well for treating most nerve pain and can have side effects.

Other treatments for nerve pain

Your doctor may recommend other treatments for pain, including

  • physical therapy to improve your strength and balance
  • a bed cradle, a device that keeps sheets and blankets off your legs and feet while you sleep

Diabetes experts have not made special recommendations about supplements for people with diabetes. For safety reasons, talk with your doctor before using supplements or any complementary or alternative medicines or medical practices.

References

Autonomic Neuropathy

What is autonomic neuropathy?

Autonomic neuropathy is damage to nerves that control your internal organs.

Autonomic neuropathy can lead to problems with your

What causes autonomic neuropathy?

Over time, high blood glucose and high levels of fats, such as triglycerides, in the blood from diabetes can damage your nerves and the small blood vessels that nourish your nerves, leading to autonomic neuropathy.

What are the symptoms of autonomic neuropathy?

The symptoms of autonomic neuropathy depend on which of your body’s functions are affected.

Heart rate and blood pressure

Damage to the nerves that control your heart rate and blood pressure may make these nerves respond more slowly to a change in your body’s position, stress, physical activity, sleep, and breathing patterns. You may feel light-headed or faint when you stand up from lying down or sitting, or when you do a physical activity. You may have a rapid heart rate, or your heart rate may suddenly speed up or slow down. Nerve damage can also prevent you from feeling chest pain when your heart is not getting enough oxygen or when you are having a heart attack.

Digestive system

Damage to the nerves of your digestive system can cause symptoms such as the following:

Autonomic neuropathy may also cause gastroparesis. Gastroparesis is a disorder that slows or stops the movement of food from your stomach to your small intestine. Gastroparesis can keep your body from absorbing glucose and using insulin properly. These problems can make it hard to manage your blood glucose.

Bladder

Damage to the nerves of your bladder may make it hard to know when you need to urinate and when your bladder is empty. This damage can cause you to hold urine for too long, which can lead to bladder infections. You may also leak drops of urine. Leaking urine or not being able to hold urine is called urinary incontinence.

Sex organs

In men, damage to nerves in the sex organs may prevent the penis from getting firm when a man wants to have sex. This condition is called erectile dysfunction, also called ED. Men also may have problems with ejaculation.

In women, damage to the nerves in the sex organs can prevent the vagina from getting wet when a woman wants to have sex. A woman might also have less feeling around her vagina and may have trouble having an orgasm.

Sweat glands

Damage to the nerves that control your sweat glands may cause you to sweat a lot at night or while eating. Your sweat glands may not work at all, or certain parts of your body may sweat while other parts are dry. If your sweat glands do not work properly, your body may not be able to control its temperature.

Eyes

Damage to the nerves in your pupils may make them slow to respond to changes in light and darkness. Your eyes may take longer to adjust when you enter a dark room. You may have trouble seeing the lights of other cars when driving at night.

Ability to feel symptoms of hypoglycemia

Autonomic neuropathy can cause hypoglycemia unawareness, meaning that you don’t feel the symptoms of low blood glucose. Normally, early symptoms of low blood glucose can include feeling confused, dizzy, hungry, irritable, or nervous. If nerve damage keeps you from feeling these symptoms, you may not take steps to treat your low blood glucose. Without treatment, you may develop severe hypoglycemia, which can cause you to pass out. You will need help right away to deal with severe hypoglycemia.

How do doctors diagnose autonomic neuropathy?

Doctors diagnose autonomic neuropathy based on your symptoms, family and medical history, a physical exam, and tests. Your doctor will check your heart rate and blood pressure and may perform additional tests to check for different types of autonomic nerve damage.

Doctor checking a patient’s blood pressure.
Your doctor will check your heart rate and blood pressure and may perform other tests to check for different types of autonomic nerve damage.

What tests do doctors use to diagnose autonomic neuropathy?

To diagnose autonomic neuropathy, your doctor may use a few tests to assess changes in your heart rate in response to simple movements such as deep breathing or standing. Your doctor may also use tests to check your sweat function to know how your nerves and sweat glands are working.

Depending on your symptoms, you doctor may also use

  • tests to rule out other causes of digestive symptoms, such as constipation and diarrhea
  • gastric emptying scintigraphy and gastric emptying breath tests to diagnose gastroparesis
  • ultrasounds of your bladder and urinary tract to check how your bladder is working
  • blood pressure checks while you are lying down and then after you stand up

How can I help treat autonomic neuropathy?

You can help treat autonomic neuropathy by managing your diabetes, which means managing your blood glucose, blood pressure, and cholesterol. Staying close to your goal numbers can keep nerve damage from getting worse.

How do doctors treat autonomic neuropathy?

Your doctor may treat the symptoms caused by autonomic nerve damage.

Heart rate and blood pressure

Your doctor will treat the symptoms of nerve damage that affect your heart rate and blood pressure. Your doctor may recommend

  • getting more physical activity
  • increasing salt in your diet if your blood pressure drops too low when you stand up
  • increasing the amount of liquids you drink
  • raising the head of your bed or wearing elastic stockings to improve blood flow
  • sitting or standing slowly to prevent light-headedness or fainting
  • avoiding hypoglycemia

Your doctor may also prescribe medicines that help your body retain salt, medicines to help raise your blood pressure, or medicines that raise or lower your heart rate.

Digestive system

Your doctor may recommend changes to your diet and over-the-counter or prescription medicines to treat digestive symptoms and problems such as

  • constipation
  • diarrhea
  • fecal incontinence
  • gastroesophageal reflux
  • gastroparesis

Read more about these digestive symptoms and problems.

Talk with your doctor before taking any over-the-counter medicines to treat problems with digestion. Your doctor may refer you to a gastroenterologist for treatment.

Bladder

Your doctor will treat your bladder problems by focusing on your symptoms. If you have incontinence, your doctor may recommend planning regular trips to the bathroom because you may not be able to tell when your bladder is full.

Your doctor may also prescribe medicines to help with incontinence or help if you have problems completely emptying your bladder.

If you have a bladder infection, your doctor may prescribe an antibiotic and suggest drinking plenty of liquids to help prevent future infections.

Sex organs

Doctors may recommend medicines or devices to treat erectile dysfunction. Doctors may refer men to a urologist to treat sexual problems.

To treat sexual problems in women, doctors may refer women to a gynecologist. Doctors may recommend vaginal lubricants when neuropathy causes vaginal dryness.

Sweat glands

If you have too much sweating, your doctor may suggest

  • avoiding too much heat or humidity
  • a prescription antiperspirant or medicine to decrease sweating
  • surgery to cut the nerves in the sweat glands or to remove sweat glands

Hypoglycemia unawareness

If diabetes-related nerve damage leads to hypoglycemia unawareness, you may need to check your blood glucose more often, so you know when you need to treat hypoglycemia or take steps to prevent it.

Your doctor may prescribe a continuous glucose monitor (CGM). A CGM checks your blood glucose levels at regular times throughout the day and night. CGMs can tell you if your blood glucose is falling quickly and sound an alarm if your blood glucose falls too low.

If you pass out due to severe hypoglycemia, someone will need to give you a glucagon injection and call 9-1-1. An injection of glucagon will quickly raise your blood glucose back to normal. Ask your doctor about when and how to use a glucagon emergency kit. Consider wearing a diabetes medical alert ID bracelet or pendant. If you pass out, this medical alert ID will tell other people that you have diabetes and need care right away.

Focal Neuropathies

What are focal neuropathies?

Focal neuropathies are conditions in which you typically have damage to single nerves, most often in your hand, head, torso, or leg. This type of nerve damage is less common than peripheral or autonomic neuropathy.

Many different focal neuropathies can affect people who have diabetes.

Entrapments

Entrapments, or entrapment syndromes, are the most common type of focal neuropathy. Entrapments occur when nerves become compressed or trapped in areas where nerves pass through narrow passages between bones and tissues. People with diabetes are more likely to have entrapments than people without diabetes.1

The most common entrapment is called carpal tunnel syndrome. Although less than 10 percent of people with diabetes feel symptoms of carpal tunnel syndrome, about 25 percent of people with diabetes have some nerve compression at the wrist.2

Other focal neuropathies

Other focal neuropathies that do not involve trapped nerves are much less common. These focal neuropathies most often affect older adults. Examples include cranial neuropathies, which affect the nerves of the head. Cranial neuropathies can cause eye problems or problems with the muscles of the face. Symptoms depend on which nerve is affected.

What causes focal neuropathies?

Over time, high blood glucose, also called blood sugar, and high levels of fats, such as triglycerides, in the blood from diabetes can damage your nerves and the small blood vessels that nourish your nerves, leading to focal neuropathies.

What are the symptoms of focal neuropathies?

Entrapments—focal neuropathies that involve trapped nerves—cause symptoms that begin gradually and get worse over time. Examples include

  • carpal tunnel syndrome, which causes pain, numbness, and tingling in your thumb, index finger, and middle finger, and sometimes weakness of your grip
  • ulnar entrapment, which causes pain, numbness, and tingling in your little and ring fingers
  • peroneal entrapment, which causes pain on the outside of your lower leg and weakness in your big toe
Woman holding her painful wrist.
The most common entrapment is carpal tunnel syndrome.

Focal neuropathies that do not involve trapped nerves cause symptoms that begin suddenly and improve after several weeks or months. Depending on which nerve is affected, you may have pain and other symptoms in your

  • hand
  • leg
  • foot
  • torso

Cranial neuropathies—focal neuropathies that affect the nerves in the head—may cause symptoms such as

  • aching behind one eye
  • double vision
  • paralysis on one side of your face, called Bell’s palsy
  • problems focusing your eyes

How do doctors diagnose focal neuropathies?

Doctors diagnose focal neuropathies by asking about your symptoms and performing tests, such as nerve conduction studies and electromyography (EMG). Nerve conduction studies check how fast electrical signals move through your nerves in different parts of your body. EMG shows how your muscles respond to your nerves.

How do doctors treat focal neuropathies?

Your doctor may treat focal neuropathy pain with the same medicines used to treat peripheral neuropathy pain.

To treat a focal neuropathy that involves a trapped nerve, your doctor may recommend

  • wearing a splint or brace to take pressure off the nerve
  • medicines that reduce inflammation
  • surgery, if other treatments don’t work

For focal neuropathies that don’t involve trapped nerves, most people recover within a few weeks or months, even without treatment.

References

Proximal Neuropathy

What is proximal neuropathy?

Proximal neuropathy is a rare and disabling type of nerve damage in your hip, buttock, or thigh. This type of nerve damage typically affects one side of your body and may rarely spread to the other side.

Proximal neuropathy is more common in men than in women and more common in people older than age 50. Most people with this condition have type 2 diabetes.

What causes proximal neuropathy?

Over time, high blood glucose, also called blood sugar, and high levels of fats, such as triglycerides, in the blood from diabetes can damage your nerves and the small blood vessels that nourish your nerves, leading to proximal neuropathy.

What are the symptoms of proximal neuropathy?

Symptoms may include

  • sudden and sometimes severe pain in your hip, buttock, or thigh
  • weakness in your legs that makes it difficult to stand from a sitting position
  • loss of reflexes such as the knee-jerk reflex—the automatic movement of your lower leg when a doctor taps the area below your knee cap
  • muscle wasting, or the loss of muscle tissue
  • weight loss

After symptoms start, they typically get worse and then gradually improve over a period of months or years. In many cases, the symptoms do not go away completely.

Man standing up from sitting with a hand on his painful hip.
Symptoms of proximal neuropathy may include sudden and sometimes severe pain in your hip, buttock, or thigh.

How do doctors diagnose proximal neuropathy?

Doctors diagnose proximal neuropathy by asking about your symptoms and performing tests, such as nerve conduction studies and electromyography (EMG). Nerve conduction studies check how fast electrical signals move through your nerves in different parts of your body. EMG shows how your muscles respond to your nerves.

How can I help treat proximal neuropathy?

You can help treat proximal neuropathy by managing your diabetes, which means managing your blood glucose, blood pressure, and cholesterol.

How do doctors treat proximal neuropathy?

Your doctor may treat the pain of proximal neuropathy with the same medicines used to treat peripheral neuropathy pain.

Your doctor may also recommend physical therapy to help increase your strength, and occupational therapy to help you with daily activities.

Most people recover from proximal neuropathy within a few years, even without treatment.

February 2018
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This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.

The NIDDK would like to thank:
Rodica Pop-Busui, M.D., Ph.D., University of Michigan