Nerve pain
Peripheral Neuropathy
Numb, burning feet or hands without diabetes? Gulf Coast Pain & Spine in Houston explains causes, workup, nerve pain drugs and when stimulation is used.
Peripheral neuropathy is damage to the nerves outside the brain and spinal cord, most often the long nerves to the feet and hands. Diabetes is the leading cause, but roughly half of cases have another explanation: vitamin B12 deficiency, alcohol, chemotherapy, thyroid disease, autoimmune conditions, inherited disorders, or no identifiable cause at all. Gulf Coast Pain & Spine works through the cause with your primary care physician or neurologist, treats the pain with the medications that have the best evidence, and considers spinal cord stimulation for pain that does not respond.
Key facts
| What it is | Damage to peripheral nerves producing numbness, tingling, burning pain, and sometimes weakness, usually starting in the toes and feet |
|---|---|
| Most common causes | Diabetes and prediabetes, vitamin B12 deficiency, alcohol, chemotherapy, hypothyroidism, autoimmune disease, kidney disease, inherited neuropathy; 20 to 30 percent remain idiopathic after a full workup |
| Typical course | Depends on the cause: B12 and thyroid neuropathy can improve with treatment, chemotherapy neuropathy often improves over 6 to 12 months, idiopathic neuropathy is usually slow and stable |
| See a specialist when | Symptoms are spreading, disturbing sleep or balance, or the cause has not been found; weakness or rapid change needs neurology promptly |
| Treatments we offer | Medication management, topical treatments, coordination of the workup, spinal cord stimulation trial and implant for refractory painful neuropathy |
When to get emergency care
Go to an emergency room or call 911 if you have:
- Weakness that is spreading up from the feet or hands over hours to days, or trouble walking, swallowing or breathing (Guillain-Barre syndrome can progress rapidly and needs hospital care)
- Numbness or weakness that came on suddenly, or that affects one limb or one side of the face (possible stroke or nerve compression)
- New loss of bowel or bladder control, or numbness in the groin and inner thighs
- A numb foot with a new sore, a hot red swollen foot, or a wound that is not healing
- Neuropathy with unexplained weight loss, fevers, night sweats or a purple rash on the legs (possible vasculitis or cancer-related neuropathy needing prompt workup)
A neuropathy that started within the last few weeks, is patchy and asymmetric, or involves significant weakness is not a pain-clinic problem first; it needs neurology, and we will help arrange that.
What peripheral neuropathy is
Your peripheral nerves carry sensation from the skin and joints to the spinal cord, and commands from the spinal cord to the muscles. When they are damaged, the longest ones suffer first, which is why most neuropathies begin in the toes and follow a "stocking and glove" pattern. Large sensory fibers carry vibration and position sense (loss causes imbalance); small fibers carry pain and temperature (damage causes burning pain and numbness to hot and cold); motor fibers drive muscles (damage causes weakness and wasting); and autonomic fibers regulate blood pressure, sweating and digestion.
About 2 to 3 percent of the general population has peripheral neuropathy, rising to about 8 percent after age 55. Diabetes accounts for roughly a third to a half of cases, and that form is covered separately on our diabetic peripheral neuropathy page. This page is about everything else, and about what to do when the cause is never found. Gulf Coast Pain & Spine sees neuropathy patients in Houston, Webster and Pearland (opening November 2026).
Causes other than diabetes
The list is long, but a handful of causes account for most cases, and several are treatable or reversible:
- Vitamin B12 deficiency: from low intake (vegan diets), poor absorption (pernicious anemia, stomach surgery, celiac disease), or long-term metformin, acid-suppressing drugs or nitrous oxide use. Replacing B12 can halt and partly reverse the damage.
- Alcohol: both a direct toxin and a cause of thiamine (B1) and other deficiencies. Stopping alcohol is the treatment.
- Chemotherapy (platinum drugs, taxanes, vinca alkaloids, bortezomib, thalidomide): chemotherapy-induced peripheral neuropathy affects up to two-thirds of patients receiving these agents and often improves over 6 to 12 months after treatment ends, though it can be permanent.
- Hypothyroidism and, less often, other endocrine disorders.
- Autoimmune and inflammatory disease: Sjogren's syndrome, rheumatoid arthritis, lupus, sarcoidosis, celiac disease, vasculitis, and immune-mediated neuropathies such as chronic inflammatory demyelinating polyneuropathy (CIDP), which is treatable with immune therapy.
- Kidney and liver disease, and abnormal blood proteins (monoclonal gammopathy, amyloidosis).
- Infections: HIV, hepatitis C, Lyme disease, shingles (see postherpetic neuralgia).
- Inherited neuropathies such as Charcot-Marie-Tooth, often with high arches, hammer toes and a family history.
- Medications and toxins: some antibiotics, amiodarone, phenytoin, heavy metals.
- Idiopathic: in 20 to 30 percent of patients, a full workup finds no cause. This is common after age 60, tends to be slowly progressive and sensory-predominant, and is treated for symptoms.
Symptoms, and what points to a specific cause
Most neuropathies produce numbness, tingling, pins and needles, and burning or stabbing pain in the feet, worse at night, along with unsteadiness in the dark. Some features point toward a cause and change the workup:
- Symmetric, slow, feet-first: typical of metabolic causes (diabetes, B12, thyroid, alcohol, idiopathic)
- Started with chemotherapy: usually clear from timing; taxanes and platinum drugs are the usual culprits
- Patchy, one nerve at a time, or asymmetric: suggests vasculitis, diabetes-related mononeuropathy, or an entrapment; needs faster evaluation
- Rapid onset over days to weeks with weakness: Guillain-Barre syndrome or CIDP; needs neurology urgently
- Weakness out of proportion to numbness, with high arches: inherited neuropathy
- Dizziness on standing, digestive or bladder problems, abnormal sweating: autonomic involvement, seen in diabetes, amyloidosis and some autoimmune neuropathies
Look-alikes worth separating: lumbar spinal stenosis causes leg symptoms that worsen with standing and walking and ease with sitting or leaning forward; carpal tunnel syndrome causes hand numbness in the thumb, index and middle fingers and spares the feet; peripheral artery disease causes calf cramping with walking and cold feet with weak pulses.
How we diagnose it
The goal of the workup is to find the causes that can be treated. The American Academy of Neurology recommends a focused set of blood tests for a typical symmetric neuropathy, because these have the highest yield:
- Glucose testing: fasting glucose, A1c, and if normal, a 2-hour oral glucose tolerance test (prediabetes is a common cause missed by A1c alone)
- Vitamin B12 with methylmalonic acid, which catches deficiency when B12 is borderline
- Serum protein electrophoresis with immunofixation to look for abnormal blood proteins
- Plus a complete blood count, kidney and liver function, and thyroid function
Additional tests are chosen by the story: vitamin B1 and B6, hepatitis C and HIV, celiac antibodies, inflammatory markers and autoimmune antibodies, and heavy metals when there is an exposure. Nerve conduction studies and EMG confirm the neuropathy, distinguish axonal from demyelinating patterns (which separates metabolic causes from treatable immune ones), and detect superimposed entrapments. When symptoms are burning pain with normal nerve conduction studies, a skin biopsy measuring small nerve fiber density can confirm small fiber neuropathy. Genetic testing is used when the pattern or family history suggests an inherited cause.
Much of this is often already done by your PCP or neurologist; bring the results. We arrange what is missing and refer to neurology when the pattern is atypical, progressive, or when an immune-mediated neuropathy is possible.
Treatment options, in order
Two tracks: treat the cause when one is found (B12 replacement, thyroid hormone, stopping alcohol or a culprit drug, immune therapy for CIDP through neurology, oncology adjustments for chemotherapy neuropathy), and treat the pain. The pain medications are the same ones used for diabetic neuropathy, and each needs 4 to 8 weeks at an adequate dose to judge.
- Treat the cause and protect the feet
Replace deficiencies, adjust or stop offending medications with the prescribing doctor, address alcohol use. With reduced sensation: daily foot checks, proper footwear, podiatry.
- First-line medication
Duloxetine (the only agent with strong evidence for chemotherapy-induced neuropathy pain), pregabalin, or gabapentin; low-dose amitriptyline or nortriptyline at bedtime when sleep is the main problem and the heart is healthy. Started one at a time, titrated to effect. Learn more →
- Topical treatments
Lidocaine 5 percent patches or cream and capsaicin (cream or the 8 percent prescription patch) on the most painful areas. Useful alone in mild cases and as add-ons in older patients who tolerate oral drugs poorly.
- Physical therapy and balance training
Loss of position sense causes falls. Balance and strength training, and sometimes an ankle brace or cane, reduce fall risk more than any medication. Learn more →
- Combination therapy
An SNRI plus a gabapentinoid, or adding a sodium-channel blocker such as oxcarbazepine or lacosamide. Opioids are not effective for neuropathic pain over the long term and are not part of the plan.
- Spinal cord stimulation
When pain remains disabling after at least two medication classes and a fair trial of each, spinal cord stimulation is considered. Evidence is strongest for painful diabetic neuropathy (10 kHz SCS is FDA-approved for that indication); for other painful neuropathies the evidence is smaller case series, and coverage is reviewed case by case by the insurer. A temporary trial of 5 to 7 days comes first, and implant follows only if the trial gives at least 50 percent relief. Learn more →
What you can do now
- Bring every lab result and the medication list. The cause is often sitting in a result nobody connected to the symptoms.
- Stop alcohol if you drink regularly; even moderate amounts slow nerve recovery.
- Ask about B12 if you take metformin or acid-suppressing drugs, or eat little animal protein.
- Fall-proof the house: night lights, no loose rugs, a rail in the shower. Neuropathy falls cause hip fractures.
- Walk daily and do balance work (standing on one foot near a counter, heel-to-toe walking).
- Keep a night-pain and walking log for two weeks so medication changes can be judged on evidence rather than impression.
New patients can start at new patient information; physicians can use the referral page.
Frequently asked questions
What if no cause is ever found?
That is the outcome for 20 to 30 percent of patients after a complete workup, most often older adults with slowly progressive numbness and burning in the feet. Idiopathic neuropathy is usually stable or slow over years and rarely causes serious weakness. Treatment focuses on pain control and fall prevention, and the workup is repeated if the pattern changes.
Will chemotherapy neuropathy go away?
Often it improves substantially over 6 to 12 months after the last dose, but a portion of patients are left with permanent numbness or pain, particularly after platinum drugs. Duloxetine is the medication with the best evidence for chemotherapy-related nerve pain. Tell your oncologist about symptoms during treatment; dose changes early can limit the damage.
Can peripheral neuropathy be cured?
When a treatable cause is found early (B12 deficiency, hypothyroidism, alcohol, a culprit medication, an immune neuropathy), nerve function can recover partly or fully over months. Once nerve fibers are lost, they regrow slowly if at all, so numbness tends to persist. Pain, however, is treatable in most patients.
Do I need to see a neurologist or a pain specialist?
Both have a role. Neurology leads when the diagnosis is unclear, the neuropathy is progressing, involves weakness, or may be immune-mediated. Pain management leads when the cause is known or idiopathic and the main problem is pain. We refer to neurology whenever the pattern calls for it.
Is spinal cord stimulation an option for non-diabetic neuropathy?
It is considered when pain is severe, has failed at least two medication classes, and function is limited. The FDA approval and the large trial evidence are for painful diabetic neuropathy; for other neuropathies the evidence is smaller, and insurers review coverage individually. A temporary trial decides whether an implant is worthwhile.
Why are my nerve conduction studies normal when my feet burn?
Nerve conduction studies measure large fibers. Burning pain and temperature numbness come from small fibers, which the test cannot see. Small fiber neuropathy is diagnosed by exam and, when needed, a skin biopsy. It is treated with the same medications.
Which shoes and socks are best?
Cushioned, wide-toed shoes with a firm sole, fitted in the afternoon when feet are largest, and seamless socks. Avoid walking barefoot. If sensation is reduced, ask about a podiatry referral for diabetic-style footwear even if you do not have diabetes.
Sources
- Peripheral Neuropathy (opens in new tab) — National Institute of Neurological Disorders and Stroke
- Practice Parameter: Evaluation of distal symmetric polyneuropathy: role of laboratory and genetic testing (opens in new tab) — American Academy of Neurology (England JD et al., Neurology 2009; PubMed)
- Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update (opens in new tab) — American Academy of Neurology, 2022
- Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update (opens in new tab) — American Society of Clinical Oncology (PubMed)
Request an appointment
Call (832) 916-2075 or request an appointment online. New patients are welcome; the team confirms insurance and referral requirements before scheduling.