Peripheral Neuropathic Pain

Peripheral neuropathic pain is pain caused by damage or disease affecting the nerves that run from your spinal cord out to your arms, legs and body. Because the nerve itself is sending faulty signals, it usually feels different from an ache or a bruise, more like burning, shooting or electric shocks. Diabetic peripheral neuropathy is the most common type, and it usually starts in the feet and works its way up over time.

What nerve pain is, and what it is not

Nerve pain is not the same as pain from a strained muscle or a worn joint, and that difference is practical rather than academic. It comes from the signalling system itself, so the same patch of skin can feel numb and painful at once, and light touch such as a bed sheet on the feet can hurt. Because the mechanism is different, the medicines used for nerve pain are often different from ordinary painkillers, and medicines that help a sore knee may do very little here.

It is also not only a complication of diabetes, although diabetes is the leading cause. Nerve pain can follow shingles, an injury or operation, a trapped nerve, some cancers and chemotherapy medicines, or an inherited nerve condition. Diabetes Canada’s guidelines state that 40% to 50% of people with type 1 and type 2 diabetes will develop detectable sensorimotor polyneuropathy within 10 years of the onset of diabetes. Nerve pain in the face is a separate condition, covered on our page for trigeminal neuralgia.

Signs and symptoms

• Burning, shooting, stabbing or electric shock sensations
• Pins and needles, tingling, or a crawling feeling in the feet or hands
• Numbness, or a feeling that your feet are wrapped in a sock or glove
• Pain from things that should not hurt, such as bed sheets touching your feet
• Symptoms that often start in both feet and slowly move up the legs, then reach the hands
• Pain that is worse at night and interferes with sleep
• Weakness, unsteadiness on your feet, or not noticing a cut or blister on the foot

Symptoms build gradually in most people, and it is common to have numbness in one area and pain in another, or to notice the pain most in the evening.

What raises the risk

Some risk factors cannot be changed:

• How long you have lived with diabetes, since risk builds with duration
• Getting older, which is linked to higher rates of neuropathic pain symptoms in Canadian survey data
• Nerve injury from trauma, surgery, shingles, or a trapped nerve
• Some cancers and chemotherapy medicines that affect nerves, and certain inherited nerve conditions

Others can often be worked on, usually with support from a health care team:

• Blood sugar levels over time, which are managed together with your diabetes care team
• Heavy alcohol use, which can damage peripheral nerves
• Smoking, high blood pressure and high cholesterol, which affect the small blood vessels that supply nerves

How peripheral neuropathy is diagnosed in Canada

Peripheral neuropathy is usually identified by a family doctor, nurse practitioner or diabetes care team through your description of the symptoms and a foot and nerve examination. Diabetes Canada advises screening with a monofilament or a tuning fork applied to the great toe, starting at diagnosis for type 2 diabetes and after five years for type 1 diabetes, and then yearly. Screening questionnaires such as the DN4 and S-LANSS help identify pain that is likely to be coming from nerves, and blood tests, nerve conduction studies or a referral to a neurologist may be used to look for other causes.

Treatment and day-to-day management

Clinical research for Peripheral Neuropathic Pain is enrolling. See the current studies ↓

Care usually works on two fronts at once: the condition causing the nerve damage, and the pain and sleep loss it produces. Depending on the cause and your other health conditions, a health care team may discuss:

• Management of the underlying cause, such as blood glucose management with a diabetes care team, plus regular foot checks and footwear advice
• Certain anticonvulsant medicines, such as gabapentinoids, prescribed for nerve pain and chosen with a clinician
• Certain antidepressant medicines used for nerve pain, including serotonin and noradrenaline reuptake inhibitors and tricyclics
• Topical treatments applied to the skin over the painful area, and physiotherapy, exercise and balance training to support strength and reduce the risk of falls
• Psychological approaches such as cognitive behavioural therapy for pain and sleep, and referral to an interdisciplinary pain clinic where one is available

Diabetes Canada’s guideline lists opioid analgesics as a category placed after other options have been considered, and opioids for chronic non-cancer pain are addressed separately by the 2024 Canadian Opioid Prescribing Guideline. Which combination fits you depends on your kidney function, your other medicines and how you respond, and those are decisions for you and your own clinician.

When to talk to a doctor

• Seek medical care the same day for a foot ulcer, an open sore, a blister that is not healing, or a foot that is red, hot, swollen or has a bad smell, since foot infections in people with neuropathy can worsen quickly. Go to an emergency department or call 911 if you also have a fever, confusion or feel very unwell.
• Call 911 or go to an emergency department for sudden weakness or numbness affecting a whole limb or one side of the body, sudden trouble speaking, or numbness with loss of bladder or bowel control.
• Book a prompt appointment if numbness, burning or weakness is spreading quickly over days to weeks, or if you are falling or feeling unsteady on your feet.

Why clinical research matters for peripheral neuropathic pain

Expectations here are worth being honest about. Diabetes Canada describes a clinically meaningful response to pain medicines as a 30% to 50% reduction in pain, so many people continue to have real symptoms and complete relief is uncommon. Nothing available today has been shown to repair nerves that are already damaged, and clinicians cannot predict which medicine will suit which person. Trials under way include new non-opioid analgesics aimed at specific ion channels and pain-signalling pathways, topical and gene-based approaches, spinal cord stimulation and other neuromodulation devices, and treatments intended to slow or reverse nerve damage rather than only mask pain.

Clinical studies are how those are tested and compared with current care. Taking part is voluntary, you give informed consent before anything begins, and you can withdraw at any time without affecting your usual diabetes or pain care. Joining a study does not mean giving up your current treatment, and no one can say in advance whether a study will help you personally.

Learn more from Canadian sources

• Diabetes Canada: Clinical Practice Guidelines, neuropathy
• Public Health Agency of Canada: diabetes in Canada surveillance highlights
• Pain BC: pain support line, education and self-management programs
• Health Canada: Canadian Pain Task Force reports