Diabetic Foot Pain and Nerve Damage (Neuropathy)

Diabetic foot pain is common, and it can have more than one cause. The most common is nerve damage from diabetes, called diabetic peripheral neuropathy. But poor blood flow, infection, Charcot foot and everyday problems such as heel strain can also make your feet hurt. This page explains how to tell them apart, how nerve damage is checked and treated in the UK, and how to look after numb feet. It is part of our wider guide to diabetic foot problems.

What causes diabetic foot pain?

Over time, high blood glucose (sugar) can damage the tiny blood vessels that feed the nerves. The nerves then stop carrying messages properly.⁷ In the UK, diabetes is the most common cause of peripheral neuropathy. The longest nerves are affected first, so symptoms usually start in the feet.³

Not all diabetic foot pain is nerve pain, though. Use the table as a starting point for a chat with your GP, practice nurse or podiatrist (foot specialist), not to diagnose yourself.

Painful and painless neuropathy

Diabetic neuropathy affects people in two quite different ways. Some people get numbness, tingling, burning, stabbing or shooting pains, sometimes with poor balance or weak foot muscles.³ These feelings, including burning feet, are often worse at night.⁷

Others mainly lose feeling. This painless type can seem less of a worry, but it is the more dangerous one for your feet. If you cannot feel pain, heat or cold, a stone in your shoe, a blister or a burn can go unnoticed and turn into an ulcer or infection.⁷ Many people have a mix of both.

Our guide to early diabetic foot symptoms covers other changes worth reporting.

Other causes of diabetic foot pain

Reduced circulation (peripheral arterial disease)

Peripheral arterial disease (PAD) means the arteries in your legs have narrowed. It usually causes cramp-like calf pain when you walk, which settles when you rest. As it gets worse, the pain can become constant and worse at night, and the foot may feel cold.⁵ If you have diabetes, a severe loss of blood supply (chronic limb-threatening ischaemia) counts as an active diabetic foot problem. It should be referred to a specialist foot service within 1 working day.¹

Charcot foot: when a numb foot swells

Charcot foot is an inflammation of the bones and joints in a foot with nerve damage. The foot becomes hot, swollen and red, but it may hurt only a little or not at all.¹ Infection can look similar, and nerve damage can dull that pain too.¹⁰ Our page on Charcot foot and diabetes explains more.

Morning heel pain and plantar fasciitis

If your foot hurts most when you first get out of bed, diabetes is often not the cause. Heel and arch pain that is worst with your first steps after rest, then eases, is typical of plantar fasciitis. This is a strain of the tissue linking your heel bone to your toes.⁶ Even so, the NHS advises people with diabetes and foot pain to see a GP.⁶

How nerve damage in the feet is assessed

Checking for nerve damage is part of every routine diabetes foot check. NICE, which sets guidance for the NHS, recommends a 10 g monofilament test.¹ This is a thin nylon thread pressed gently against your skin until it bends. Many teams also test whether you can feel vibration, using a tuning fork. They will ask about pain, cramp when walking and any changes you have noticed.⁸

Your GP may also arrange tests for other causes of neuropathy.³ Find out what else is checked at your annual diabetic foot check.

How painful diabetic neuropathy is managed

Treatment aims to ease the symptoms and stop the damage getting worse. Keeping blood glucose close to target, stopping smoking and cutting down on alcohol may help, or at least stop it getting worse.⁴ Keeping blood pressure and cholesterol in range also helps protect the nerves.⁷

Everyday painkillers often do not work for nerve pain, so doctors use medicines made for nerve pain.⁴ Only a small group is recommended, including some first developed for depression or epilepsy, and a capsaicin (chilli-based) cream for pain in one area.² Your doctor will advise which suits you and check for side effects such as drowsiness.²⁴

Your care should also include:²

• a plan that takes account of your sleep, daily life and mood
• treatments without medicines, such as physical and talking therapies
• referral to a specialist pain service if the pain is severe or stops you doing everyday things

Protecting feet that have lost feeling

Nerve damage does not always cause diabetic foot pain. If it has reduced the feeling in your feet instead, your eyes have to do the job your nerves used to do:

• Check your feet every day, using a mirror or a family member's help, and get advice quickly about any new mark or break in the skin.⁹¹¹
• Do not walk barefoot, in socks without shoes or in thin-soled slippers, indoors or outdoors.⁹
• Check inside your shoes before putting them on, and test the bath water with your wrist or elbow.¹¹
• Keep hot water bottles away from your feet.¹²
• Go to every foot review. Nerve damage on its own puts you at moderate risk and means referral to a foot protection service.¹