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Diabetic Neuropathies:

The Nerve Damage

of Diabetes
National Diabetes Information Clearinghouse

What are diabetic • neurovascular factors, leading to dam­

age to the blood vessels that carry
neuropathies? oxygen and nutrients to nerves
Diabetic neuropathies are a family of nerve
• autoimmune factors that cause inflam­
disorders caused by diabetes. People with
U.S. Department mation in nerves
of Health and diabetes can, over time, develop nerve dam­
Human Services age throughout the body. Some people with • mechanical injury to nerves, such as

nerve damage have no symptoms. Others carpal tunnel syndrome

may have symptoms such as pain, tingling, • inherited traits that increase susceptibil­
OF HEALTH or numbness—loss of feeling—in the hands, ity to nerve disease
arms, feet, and legs. Nerve problems can
• lifestyle factors, such as smoking or

occur in every organ system, including the

alcohol use

digestive tract, heart, and sex organs.

About 60 to 70 percent of people with diabe­ What are the symptoms of
tes have some form of neuropathy. People
with diabetes can develop nerve problems at diabetic neuropathies?
any time, but risk rises with age and longer Symptoms depend on the type of neuropathy
duration of diabetes. The highest rates of and which nerves are affected. Some people
neuropathy are among people who have with nerve damage have no symptoms at all.
had diabetes for at least 25 years. Diabetic For others, the first symptom is often numb­
neuropathies also appear to be more com­ ness, tingling, or pain in the feet. Symptoms
mon in people who have problems control­ are often minor at first, and because most
ling their blood glucose, also called blood nerve damage occurs over several years,
sugar, as well as those with high levels of mild cases may go unnoticed for a long time.
blood fat and blood pressure and those who Symptoms can involve the sensory, motor,
are overweight. and autonomic—or involuntary—nervous
systems. In some people, mainly those with
focal neuropathy, the onset of pain may be
What causes diabetic sudden and severe.
neuropathies? Symptoms of nerve damage may include
The causes are probably different for differ­
ent types of diabetic neuropathy. Research­ • numbness, tingling, or pain in the toes,
ers are studying how prolonged exposure to feet, legs, hands, arms, and fingers
high blood glucose causes nerve damage. • wasting of the muscles of the feet or

Nerve damage is likely due to a combination hands

of factors:
• indigestion, nausea, or vomiting
• metabolic factors, such as high blood • diarrhea or constipation
glucose, long duration of diabetes,
abnormal blood fat levels, and possibly • dizziness or faintness due to a drop in
low levels of insulin blood pressure after standing or sitting up
• problems with urination
• erectile dysfunction in men or vaginal Neuropathy Affects Nerves
dryness in women Throughout the Body
• weakness Peripheral neuropathy affects
Symptoms that are not due to neuropathy, • toes
but often accompany it, include weight loss
• feet
and depression.
• legs
• hands
What are the types of
• arms
diabetic neuropathy?
Autonomic neuropathy affects
Diabetic neuropathy can be classified as
peripheral, autonomic, proximal, or focal. • heart and blood vessels
Each affects different parts of the body in • digestive system
various ways. • urinary tract
• Peripheral neuropathy, the most • sex organs
common type of diabetic neuropathy,
• sweat glands
causes pain or loss of feeling in the toes,
feet, legs, hands, and arms. • eyes
• Autonomic neuropathy causes changes • lungs
in digestion, bowel and bladder func­ Proximal neuropathy affects
tion, sexual response, and perspiration. • thighs
It can also affect the nerves that serve
the heart and control blood pressure, • hips
as well as nerves in the lungs and eyes. • buttocks
Autonomic neuropathy can also cause • legs
hypoglycemia unawareness, a condition
in which people no longer experience Focal neuropathy affects
the warning symptoms of low blood • eyes
glucose levels. • facial muscles
• Proximal neuropathy causes pain in the • ears
thighs, hips, or buttocks and leads to
• pelvis and lower back
weakness in the legs.
• chest
• Focal neuropathy results in the sud­
den weakness of one nerve or a group • abdomen
of nerves, causing muscle weakness or • thighs
pain. Any nerve in the body can be • legs
• feet

2 Diabetic Neuropathies: The Nerve Damage of Diabetes

What is peripheral
Peripheral neuropathy, also called distal
symmetric neuropathy or sensorimotor
neuropathy, is nerve damage in the arms and
legs. Feet and legs are likely to be affected
before hands and arms. Many people with
diabetes have signs of neuropathy that a doc­
tor could note but feel no symptoms them­
selves. Symptoms of peripheral neuropathy
may include
• numbness or insensitivity to pain or


• a tingling, burning, or prickling


• sharp pains or cramps

• extreme sensitivity to touch, even light
• loss of balance and coordination
These symptoms are often worse at night.
Peripheral neuropathy may also cause mus­ Peripheral neuropathy affects the nerves in the toes,
cle weakness and loss of reflexes, especially feet, legs, hands, and arms.
at the ankle, leading to changes in the way
a person walks. Foot deformities, such as
hammertoes and the collapse of the midfoot,
may occur. Blisters and sores may appear on
numb areas of the foot because pressure or
injury goes unnoticed. If an infection occurs
and is not treated promptly, the infection
may spread to the bone, and the foot may
then have to be amputated. Many amputa­
tions are preventable if minor problems are
caught and treated in time.

3 Diabetic Neuropathies: The Nerve Damage of Diabetes

What is autonomic Hypoglycemia Unawareness
neuropathy? Normally, symptoms such as shakiness,
sweating, and palpitations occur when blood
Autonomic neuropathy affects the nerves glucose levels drop below 70 mg/dL. In
that control the heart, regulate blood pres­ people with autonomic neuropathy, symp­
sure, and control blood glucose levels. toms may not occur, making hypoglycemia
Autonomic neuropathy also affects other difficult to recognize. Problems other than
internal organs, causing problems with neuropathy can also cause hypoglycemia
digestion, respiratory function, urination, unawareness.
sexual response, and vision. In addition, the
system that restores blood glucose levels to Heart and Blood Vessels
normal after a hypoglycemic episode may
The heart and blood vessels are part of the
be affected, resulting in loss of the warning
cardiovascular system, which controls blood
symptoms of hypoglycemia.
circulation. Damage to nerves in the car­
diovascular system interferes with the body’s
ability to adjust blood pressure and heart
rate. As a result, blood pressure may drop
sharply after sitting or standing, causing a
person to feel light-headed or even to faint.
Damage to the nerves that control heart
rate can mean that the heart rate stays high,
instead of rising and falling in response to
normal body functions and physical activity.

Digestive System
Nerve damage to the digestive system most
commonly causes constipation. Damage can
also cause the stomach to empty too slowly,
a condition called gastroparesis. Severe
gastroparesis can lead to persistent nausea
and vomiting, bloating, and loss of appetite.
Gastroparesis can also make blood glucose
levels fluctuate widely due to abnormal food
Nerve damage to the esophagus may make
swallowing difficult, while nerve damage to
the bowels can cause constipation alternat­
ing with frequent, uncontrolled diarrhea,
especially at night. Problems with the diges­
Autonomic neuropathy affects the nerves in the tive system can lead to weight loss.
heart, stomach, intestines, bladder, sex organs, sweat
glands, eyes, and lungs.

4 Diabetic Neuropathies: The Nerve Damage of Diabetes

Urinary Tract and Sex Organs What is proximal
Autonomic neuropathy often affects the neuropathy?
organs that control urination and sexual
Proximal neuropathy, sometimes called lum­
function. Nerve damage can prevent the
bosacral plexus neuropathy, femoral neurop­
bladder from emptying completely, allowing
athy, or diabetic amyotrophy, starts with pain
bacteria to grow in the bladder and kidneys
in the thighs, hips, buttocks, or legs, usually
and causing urinary tract infections. When
on one side of the body. This type of neu­
the nerves of the bladder are damaged,
ropathy is more common in those with type 2
urinary incontinence may result because a
diabetes and in older adults with diabetes.
person may not be able to sense when the
Proximal neuropathy causes weakness in the
bladder is full or control the muscles that
legs and the inability to go from a sitting to
release urine.
a standing position without help. Treatment
Autonomic neuropathy can also gradu­ for weakness or pain is usually needed. The
ally decrease sexual response in men and length of the recovery period varies, depend­
women, although the sex drive may be ing on the type of nerve damage.
unchanged. A man may be unable to have
erections or may reach sexual climax with­ What is focal neuropathy?
out ejaculating normally. A woman may
have difficulty with arousal, lubrication, or Focal neuropathy appears suddenly and
orgasm. affects specific nerves, most often in the
head, torso, or leg. Focal neuropathy may
Sweat Glands cause
Autonomic neuropathy can affect the nerves • inability to focus the eye
that control sweating. When nerve dam­
• double vision
age prevents the sweat glands from work­
ing properly, the body cannot regulate its • aching behind one eye
temperature as it should. Nerve damage can • paralysis on one side of the face, called
also cause profuse sweating at night or while Bell’s palsy
• severe pain in the lower back or pelvis
Eyes • pain in the front of a thigh
Finally, autonomic neuropathy can affect the • pain in the chest, stomach, or side
pupils of the eyes, making them less respon­ • pain on the outside of the shin or inside
sive to changes in light. As a result, a person of the foot
may not be able to see well when a light
is turned on in a dark room or may have • chest or abdominal pain that is some­
trouble driving at night. times mistaken for heart disease, a
heart attack, or appendicitis
Focal neuropathy is painful and unpredict­
able and occurs most often in older adults
with diabetes. However, it tends to improve
by itself over weeks or months and does not
cause long-term damage.

5 Diabetic Neuropathies: The Nerve Damage of Diabetes

People with diabetes also tend to develop A comprehensive foot exam assesses the
nerve compressions, also called entrapment skin, muscles, bones, circulation, and sen­
syndromes. One of the most common is sation of the feet. The doctor may assess
carpal tunnel syndrome, which causes numb­ protective sensation or feeling in the feet by
ness and tingling of the hand and sometimes touching them with a nylon monofilament—
muscle weakness or pain. Other nerves similar to a bristle on a hairbrush—attached
susceptible to entrapment may cause pain on to a wand or by pricking them with a pin.
the outside of the shin or the inside of the People who cannot sense pressure from a
foot. pinprick or monofilament have lost protec­
tive sensation and are at risk for developing
foot sores that may not heal properly. The
Can diabetic neuropathies doctor may also check temperature percep­
be prevented? tion or use a tuning fork, which is more sen­
The best way to prevent neuropathy is to sitive than touch pressure, to assess vibration
keep blood glucose levels as close to the perception.
normal range as possible. Maintaining safe
blood glucose levels protects nerves through­ Other Tests
out the body. The doctor may perform other tests as part
of the diagnosis.
How are diabetic • Nerve conduction studies or electro­
neuropathies diagnosed? myography are sometimes used to help
determine the type and extent of nerve
Doctors diagnose neuropathy on the basis of damage. Nerve conduction studies
symptoms and a physical exam. During the check the transmission of electrical cur­
exam, the doctor may check blood pressure, rent through a nerve. Electromyogra­
heart rate, muscle strength, reflexes, and phy shows how well muscles respond to
sensitivity to position changes, vibration, electrical signals transmitted by nearby
temperature, or light touch. nerves. These tests are rarely needed to
diagnose neuropathy.
Foot Exams
• A check of heart rate variability shows
Experts recommend that people with dia­
how the heart responds to deep breath­
betes have a comprehensive foot exam each
ing and to changes in blood pressure
year to check for peripheral neuropathy.
and posture.
People diagnosed with peripheral neuropa­
thy need more frequent foot exams. • Ultrasound uses sound waves to pro­
duce an image of internal organs. An
ultrasound of the bladder and other
parts of the urinary tract, for example,
can be used to assess the structure
of these organs and show whether
the bladder empties completely after

6 Diabetic Neuropathies: The Nerve Damage of Diabetes

How are diabetic • anticonvulsants, such as pregabalin
(Lyrica), gabapentin (Gabarone, Neu­
neuropathies treated? rontin), carbamazepine, and lamotrig­
The first treatment step is to bring blood ine (Lamictal)
glucose levels within the normal range to • opioids and opioidlike drugs, such as
help prevent further nerve damage. Blood controlled-release oxycodone, an opi­
glucose monitoring, meal planning, physical oid; and tramadol (Ultram), an opioid
activity, and diabetes medicines or insulin that also acts as an antidepressant
will help control blood glucose levels. Symp­
toms may get worse when blood glucose is Duloxetine and pregabalin are approved by
first brought under control, but over time, the U.S. Food and Drug Administration spe­
maintaining lower blood glucose levels helps cifically for treating painful diabetic periph­
lessen symptoms. Good blood glucose con­ eral neuropathy.
trol may also help prevent or delay the onset People do not have to be depressed for an
of further problems. As scientists learn antidepressant to help relieve their nerve
more about the underlying causes of neurop­ pain. All medications have side effects, and
athy, new treatments may become available some are not recommended for use in older
to help slow, prevent, or even reverse nerve adults or those with heart disease. Because
damage. over-the-counter pain medicines such as
As described in the following sections, acetaminophen and ibuprofen may not work
additional treatment depends on the type of well for treating most nerve pain and can
nerve problem and symptom. have serious side effects, some experts rec­
ommend avoiding these medications.
Pain Relief Treatments that are applied to the skin—
Doctors usually treat painful diabetic neu­ typically to the feet—include capsaicin
ropathy with oral medications, although cream and lidocaine patches (Lidoderm,
other types of treatments may help some Lidopain). Studies suggest that nitrate
people. People with severe nerve pain may sprays or patches for the feet may relieve
benefit from a combination of medications pain. Studies of alpha-lipoic acid, an
or treatments and should consider talking antioxidant, and evening primrose oil
with a health care provider about treatment suggest they may help relieve symptoms and
options. improve nerve function in some patients.
Medications used to help relieve diabetic A device called a bed cradle can keep sheets
nerve pain include and blankets from touching sensitive feet
• tricyclic antidepressants, such as ami­ and legs. Acupuncture, biofeedback, or
triptyline, imipramine, and desipramine physical therapy may help relieve pain in
(Norpramin, Pertofrane) some people. Treatments that involve elec­
trical nerve stimulation, magnetic therapy,
• other types of antidepressants, such as and laser or light therapy may be helpful but
duloxetine (Cymbalta), venlafaxine, need further study. Researchers are also
bupropion (Wellbutrin), paroxetine studying several new therapies in clinical
(Paxil), and citalopram (Celexa) trials.

7 Diabetic Neuropathies: The Nerve Damage of Diabetes

Gastrointestinal Problems To treat erectile dysfunction in men, the doc­
To relieve mild symptoms of gastroparesis— tor will first do tests to rule out a hormonal
indigestion, belching, nausea, or vomiting— cause. Several methods are available to treat
doctors suggest eating small, frequent erectile dysfunction caused by neuropathy.
meals; avoiding fats; and eating less fiber. Medicines are available to help men have
When symptoms are severe, doctors may and maintain erections by increasing blood
prescribe erythromycin to speed digestion, flow to the penis. Some are oral medica­
metoclopramide to speed digestion and help tions and others are injected into the penis
relieve nausea, or other medications to help or inserted into the urethra at the tip of the
regulate digestion or reduce stomach acid penis. Mechanical vacuum devices can also
secretion. increase blood flow to the penis. Another
option is to surgically implant an inflatable
To relieve diarrhea or other bowel prob­ or semirigid device in the penis.
lems, doctors may prescribe an antibiotic
such as tetracycline, or other medications as Vaginal lubricants may be useful for women
appropriate. when neuropathy causes vaginal dry­
ness. To treat problems with arousal and
Dizziness and Weakness orgasm, the doctor may refer women to a
Sitting or standing up slowly may help
prevent the light-headedness, dizziness, or Foot Care
fainting associated with blood pressure and
circulation problems. Raising the head of People with neuropathy need to take special
the bed or wearing elastic stockings may also care of their feet. The nerves to the feet
help. Some people benefit from increased are the longest in the body and are the ones
salt in the diet and treatment with salt- most often affected by neuropathy. Loss
retaining hormones. Others benefit from of sensation in the feet means that sores or
high blood pressure medications. Physical injuries may not be noticed and may become
therapy can help when muscle weakness or ulcerated or infected. Circulation problems
loss of coordination is a problem. also increase the risk of foot ulcers. Smok­
ing increases the risk of foot problems and
Urinary and Sexual Problems amputation. A health care provider may be
able to provide help with quitting smoking.
To clear up a urinary tract infection, the
doctor will probably prescribe an antibiotic. More than 60 percent of all nontraumatic
Drinking plenty of fluids will help prevent lower-limb amputations in the United States
another infection. People who have incon­ occur in people with diabetes. Nontraumatic
tinence should try to urinate at regular amputations are those not caused by trauma
intervals—every 3 hours, for example— such as severe injuries from an accident.
because they may not be able to tell when In 2004, about 71,000 nontraumatic amputa­
the bladder is full. tions were performed in people with diabe­
tes. Comprehensive foot care programs can
reduce amputation rates by 45 to 85 percent.

8 Diabetic Neuropathies: The Nerve Damage of Diabetes

Careful foot care involves
• cleaning the feet daily using warm— Points to Remember
not hot—water and a mild soap. Soak­ • Diabetic neuropathies are nerve
ing the feet should be avoided. A soft disorders caused by many of the
towel can be used to dry the feet and abnormalities common to diabetes,
between the toes. such as high blood glucose.
• inspecting the feet and toes every day • Neuropathy can affect nerves
for cuts, blisters, redness, swelling, throughout the body, causing
calluses, or other problems. Using a numbness and sometimes pain in
mirror—handheld or placed on the the hands, arms, feet, or legs, and
floor—may be helpful in checking the problems with the digestive tract,
bottoms of the feet, or another person heart, sex organs, and other body
can help check the feet. A health care systems.
provider should be notified of any • Treatment first involves bringing
problems. blood glucose levels within the
• using lotion to moisturize the feet. normal range. Good blood glucose
Getting lotion between the toes should control may help prevent or delay
be avoided. the onset of further problems.
• filing corns and calluses gently with a • Foot care is an important part of
pumice stone after a bath or shower. treatment. People with neuropathy
• cutting toenails to the shape of the need to inspect their feet daily for
toes and filing the edges with an emery any injuries. Untreated injuries
board each week or when needed. increase the risk of infected foot
sores and amputation.
• always wearing shoes or slippers to pro­
tect feet from injuries. Wearing thick, • Treatment also includes pain relief
soft, seamless socks can prevent skin and other medications as needed,
irritation. depending on the type of nerve
• wearing shoes that fit well and allow the
toes to move. New shoes can be broken • Smoking increases the risk of foot
in gradually by first wearing them for problems and amputation. A
only an hour at a time. health care provider may be able to
provide help with quitting.
• looking shoes over carefully before put­
ting them on and feeling the insides to
make sure the shoes are free of tears,
sharp edges, or objects that might injure Hope through Research
the feet.
The National Institute of Diabetes and Diges­
People who need help taking care of their tive and Kidney Diseases (NIDDK) conducts
feet should consider making an appointment and supports research to help people with
to see a foot doctor, also called a podiatrist. diabetes.
Participants in clinical trials can play a more
active role in their own health care, gain access
to new research treatments before they are
widely available, and help others by contribut­
ing to medical research. For information about
current studies, visit
9 Diabetic Neuropathies: The Nerve Damage of Diabetes
For More Information For more information, contact the following
See the following publications from the
NIDDK for more information about topics American Diabetes Association
related to diabetic neuropathies: 1701 North Beauregard Street
Alexandria, VA 22311
• Gastroparesis—stomach nerve
Phone: 1–800–DIABETES (342–2383)
damage—available online at www.
• Hypoglycemia—available online at American Podiatric Medical Association 9312 Old Georgetown Road
hypoglycemia Bethesda, MD 20814–1621
Phone: 1–800–FOOTCARE (366–8227)
• Nerve Disease and Bladder Control— or 301–581–9200
available online at www.kidney.niddk. Fax: 301–530–2752 Email:
• Prevent diabetes problems: Keep your Internet:
feet and skin healthy and Prevent diabe­
tes problems: Keep your nervous system American Urological Association
healthy, two publications in the Prevent Foundation
Diabetes Problems Series—available 1000 Corporate Boulevard
online at Linthicum, MD 21090
dm/pubs/complications Phone: 1–866–RING–AUA (746–4282)
or 410–689–3700
• Sexual and Urologic Problems of
Fax: 410–689–3800
Diabetes—available online at www.
• Take Care of Your Feet for a Lifetime,
available from the National Diabe­
Centers for Disease Control and Prevention
tes Education Program by calling
National Center for Chronic Disease Pre­
1–888–693–NDEP (6337) or visiting
vention and Health Promotion
Division of Diabetes Translation
4770 Buford Highway NE, Mail Stop K–10
These publications are also available by call­ Atlanta, GA 30341–3717
ing 1–800–860–8747. Phone: 1–800–CDC–INFO (232–4636)
or 770–488–5000

10 Diabetic Neuropathies: The Nerve Damage of Diabetes

Juvenile Diabetes Research Foundation National Institute of Neurological Disorders
International and Stroke
120 Wall Street P.O. Box 5801
New York, NY 10005–4001 Bethesda, MD 20824
Phone: 1–800–533–CURE (2873) Phone: 1–800–352–9424
Fax: 212–785–9595 or 301–496–5751
Email: Internet:
National Kidney and Urologic Diseases
Lower Extremity Amputation Prevention Information Clearinghouse
Program 3 Information Way
Health Resources and Services Bethesda, MD 20892–3580
Administration Phone: 1–800–891–5390
5600 Fishers Lane TTY: 1–866–569–1162
Rockville, MD 20857 Fax: 703–738–4929
Phone: 1–888–ASK–HRSA (275–4772) Email:
Internet: Internet:
National Diabetes Education Program Pedorthic Footwear Association
1 Diabetes Way 2025 M Street NW, Suite 800
Bethesda, MD 20814–9692 Washington, DC 20036
Phone: 1–888–693–NDEP (6337) Phone: 1–800–673–8447
TTY: 1–866–569–1162 or 202–367–1145
Fax: 703–738–4929 Fax: 202–367–2145
Email: Email:
Internet: Internet:
National Digestive Diseases Information
2 Information Way
Bethesda, MD 20892–3570
Phone: 1–800–891–5389
TTY: 1–866–569–1162
Fax: 703–738–4929
National Heart, Lung, and Blood Institute
Information Center
P.O. Box 30105
Bethesda, MD 20824–0105
Phone: 301–592–8573
Fax: 240–629–3246

11 Diabetic Neuropathies: The Nerve Damage of Diabetes

You may also find additional information about this National Diabetes
topic by
• searching the NIDDK Reference Collection at
Information Clearinghouse 1 Information Way
• visiting MedlinePlus at
Bethesda, MD 20892–3560
Phone: 1–800–860–8747
This publication may contain information about med­ TTY: 1–866–569–1162
ications. When prepared, this publication included
the most current information available. For updates Fax: 703–738–4929
or for questions about any medications, contact Email:
the U.S. Food and Drug Administration toll-free at Internet:
1–888–INFO–FDA (463–6332) or visit
Consult your doctor for more information. The National Diabetes Information
Clearinghouse (NDIC) is a service of the
National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK). The NIDDK
The U.S. Government does not endorse or favor any is part of the National Institutes of Health of
specific commercial product or company. Trade, the U.S. Department of Health and Human
proprietary, or company names appearing in this
document are used only because they are considered Services. Established in 1978, the Clearinghouse
necessary in the context of the information provided. provides information about diabetes to people
If a product is not mentioned, the omission does not with diabetes and to their families, health
mean or imply that the product is unsatisfactory. care professionals, and the public. The NDIC
answers inquiries, develops and distributes
publications, and works closely with professional
and patient organizations and Government
agencies to coordinate resources about diabetes.
Publications produced by the Clearinghouse are
carefully reviewed by both NIDDK scientists and
outside experts. This publication was originally
reviewed by Peter J. Dyck, M.D., Peripheral
Neuropathy Research Laboratory, Mayo Clinic
Rochester, Rochester, MN; Eva L. Feldman,
M.D., Ph.D., Department of Neurology,
University of Michigan, Ann Arbor, MI; and
Aaron I. Vinik, M.D., Ph.D., Strelitz Diabetes
Research Institute, Eastern Virginia Medical
School, Norfolk, VA. Dr. Feldman also reviewed
the updated version of the publication.

This publication is not copyrighted. The Clearinghouse

encourages users of this fact sheet to duplicate and
distribute as many copies as desired.
This fact sheet is also available at


National Institutes of Health

NIH Publication No. 09–3185

February 2009