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Nerve pain in the feet can be caused by various conditions. In this article, you’ll learn common conditions that can cause nerve pain in the feet and how they are treated.
Autonomic and Peripheral Nervous System
The peripheral nervous system, which includes the somatic and autonomic nervous systems, plays a crucial role in sensation and muscle function in the feet.
Different types of axons in the nerves are responsible for light touch, pain, temperature sensation, vibration sensation, and proprioception.
Peripheral neuropathy affects the peripheral nerves and can result in a loss of these sensations, balance issues, and an inability to differentiate between hot and cold temperatures, which can increase the risk of burns or frostbite.
Treating neuropathy can be difficult and frustrating.
Apart from peripheral neuropathy, nerve pain in the foot can also be caused by pinched nerves from the back or foot, neuromas, medications, and other medical conditions.
Causes of Neuropathy
1) Peripheral Neuropathy in the feet
Many people suffer from peripheral neuropathy. Diabetics in particular, are at higher risk for developing neuropathy in the feet. With elevated blood sugar levels, nerve damage can occur.
Volmer-Thole in the International Journal Of Molecular Sciences stated that nearly 50% of patients with diabetes develop neuropathy within 25 years of disease onset (1).
This is concerning because diabetic neuropathy can cause serious problems in your feet.
Symptoms of Neuropathy in the Foot
- Numbness in the foot
When you have neuropathy in your foot, you may step on objects and be unaware of it.
For instance, when someone who doesn’t have neuropathy steps on a needle, their pain signals become activated and alert their brain of injury.
In someone who has complete neuropathy, this pain is not felt by them. The person may not know that they even stepped on a needle.
This can cause an ulcer to form, which can then lead to a skin infection. The skin infection can turn into a bone infection and lead to amputation.
Infected ulcers need a combination of antibiotics and wound care to heal.
You can read more about diabetic foot ulcers in this supplemental post here.
- Inability to differentiate between hot and cold
Some people cannot differentiate between hot and cold due to neuropathy in the feet.
Simple things like taking a shower, soaking the feet, and even electric heated blankets can cause burns.
People who have neuropathy need to be cautious when out in the cold weather to prevent frostbite.
- Pins and needles sensations/burning
Neuropathy can also cause pins and needle/burning sensations in the feet. This can be quite bothersome and can get worse with walking. This sensation can also last throughout the night, making it more difficult to fall asleep.
- Muscle weakness
Neuropathy can also affect the muscles of the feet. Your reflexes may not be strong and certain muscles can become weaker over time. This can cause balance issues in people.
If you have long-standing neuropathy, you may suddenly feel like you are struggling more with balance. This can put you at a higher risk of falling.
Diagnosis
Your doctor will do a physical exam to determine whether you have neuropathy. A Semmes-Weinstein monofilament wire 5.07/10g is a wire that’s used to check sensation in different parts of your feet.
This can alert your doctor if you have numbness in your feet.
Your doctor will also check the vibratory sensation in your foot using a 128Hz tuning fork. Being able to feel vibration is important.
If you can’t feel the vibration in your feet, you may be at a higher risk of developing a foot ulcer.
An interesting study done by Ennion in The South African Journal of Physiotherapy, did a case study on a patient who suffered from sensory peripheral neuropathy.
The patient was instructed to wear a vibrating insole for 20 minutes a day for 35 days. Stimulating vibration in this patient’s feet improved the patient’s perception of vibration in his feet (2).
Improved vibration in the feet can help prevent foot ulcers.
Your doctor will also check if you can feel a sharp and dull sensation in your feet. Your doctor will break a Q-tip and check if you can feel the sharp side and the dull side of the Q-tip. If you can’t feel the difference between the sharp and dull side, you have neuropathy.
Your doctor will also want to check how you walk. By doing a gait exam, your doctor will be able to assess your foot structure for any foot deformities. He/she will also be able to determine whether you are struggling with balance when you walk. Balance issues occur as a result of nerve damage.
By assessing your foot structure and your gait, your doctor can provide recommendations on how to offload your foot using pads/shoes/insoles/braces.
Treatment
Medications
Experiencing constant nerve pain on the foot can affect your quality of life. It’s best to talk to your doctor regarding medications for neuropathy that may work for you.
Certain antidepressants, Gabapentinoids, Tramadol, Lidocaine, and Capsaicin are good options for neuropathy (3).
Some of the common medications used to treat diabetic peripheral neuropathy include:
- Gabapentin
- Lyrica
- Tramadol
- Nortriptyline/Amitriptyline
- Duloxetine
- Topicals such as Lidocaine and Capsaicin
Your doctor will start you on oral medication in low doses initially to help reduce pain and help you sleep. However, it’s important to be cautious of side effects that can occur, such as fatigue. These side effects can be bothersome to some people.
Your doctor may also recommend topical therapy for diabetic neuropathy.
Lidocaine can be obtained in cream form or patch (Lidocaine 5% patch). This medication can help numb your feet and reduce pain.
You can obtain Aspercreme with Lidocaine 4% cream online. This can be beneficial for nerve pain, fairly cheap, and safe.
If you need stronger strength Lidocaine, such as the Lidocaine 5% patch, you will need a prescription.
Capsaicin cream can be purchased over the counter or in prescription form (Capsaicin 8% patch). It has been used for the management of neuropathic pain (4). Capsaicin helps to decrease pain signals to the brain.
However, Capsaicin is the active ingredient in chili peppers, so the cream can initially cause a burning sensation to occur. After application, make sure you don’t take a hot shower, as this can worsen your symptoms!
Other Treatments for Diabetic Neuropathy
- Diabetic shoes/insoles
Diabetic shoes and inserts are specifically designed for patients who suffer from peripheral neuropathy. Diabetic shoes are designed to be extra-depth, and can appropriately accommodate patients’ feet.
Diabetic plastazote inserts are great for people who have diabetic neuropathy because they help to prevent shear and blisters.
It’s important to get the right shoes/insoles, especially if you have a history of a foot ulcer.
There are a variety of companies that dispense diabetic shoes and inserts. Certain insurances may cover a free pair of shoes with 3 pairs of inserts a year. You can inquire about this with your insurance company.
Also, your doctor will recommend custom plastazote insoles for your unique foot structure.
This means that if you have an ulcer in the ball of your foot, your orthotic can be designed uniquely for you with appropriate offloading to keep pressure away from your ulcer when you are walking.
Custom orthotics allow for a variety of modifications.
- Braces/boots
Since neuropathy can cause weakness, you may have issues with drop foot. In this case, you would benefit from wearing an Ankle Foot Orthosis (AFO) brace.
An AFO device helps with instability issues in your foot and ankle by maintaining your foot’s alignment and at the same time controlling motion.
You will need to see a Prosthetist to be fitted to ensure the brace is an appropriate fit and will fit into your shoes comfortably.
Some people require additional support for their diabetic foot and may require specialized boots.
A portion of diabetics will develop Charcot arthropathy. This is a syndrome that occurs due to neuropathy. People with Charcot may develop fractures in their bones which eventually cause foot collapse.
A Charcot Restraint Orthotic Walker (CROW) boot may be used to help stabilize the foot when walking. It reduces pressure and helps avoid future breaks in the bone.
2) Morton’s Neuroma
Another cause of nerve pain on the foot is a neuroma.
A Morton’s neuroma is a compression neuropathy that occurs on the ball of the foot. It is localized between your third and fourth knuckle bones (3rd intermetatarsal space). This nerve can become compressed in some people and cause pain.
The cause of neuromas is not completely known, however certain conditions such as overly flat feet, or high arch feet may aggravate the condition.
Hammertoes may also be visible in people who have issues with neuromas. If you have hammertoes, the buckling effect of your curved toes may cause excessive pressure to be placed on the ball of your foot, causing nerve pain on your foot.
Shoe gear, such as wearing shoes that are too narrow can cause worsening nerve pain on the foot. Even wearing high heels can cause excessive pressure to be placed on the ball of your foot.
Although Morton’s neuroma is the most common form of neuroma seen in the third intermetatarsal space, it can form anywhere in the foot.
The second intermetatarsal space is the second most common location, followed by the fourth intermetatarsal space.
Make sure to pay attention to your symptoms and notify your doctor about where exactly you feel pain and which toes are affected. This can give your doctor clues on where the nerve may be pinched.
Symptoms
- Sharp or burning pain
- Pain that starts in the ball of your foot and progresses into the toes
- A feeling that your sock may be bunched up even though it is not
Diagnosis
A Morton’s neuroma can be diagnosed by your doctor with a physical exam. Your doctor will examine the different areas in your feet if he/she suspects a neuroma based on your symptoms.
Your doctor will also want to order an x-ray to assess your foot structure and see where a pinched nerve may be more likely to occur.
Your doctor may also choose to order an MRI to visualize the neuroma. The MRI allows your doctor to visualize your bones, nerves, and soft tissues. This becomes important for surgical planning.
Treatment
Non-Surgical
- Neuroma pads
So you now know that Morton’s neuroma can form from excessive pressure on the ball of your foot.
Neuroma pads are very beneficial because they can be placed on your foot or in your shoes to offload the ball of the foot.
This will naturally help decrease pain with every step you take.
Some people prefer to place them directly on the foot. However, the pads must be applied in the correct location to be beneficial.
Check out Dr. Jeffrey Oster’s youtube video on how to properly apply the pad to your inserts and shoes.
You can even make your pads using ¼” felt.
Here is an example where I made my own using a sheet of 1/4″ felt.
- Orthotics
Orthotics with neuroma offloading pads in them can be beneficial to help alleviate discomfort associated with a neuroma. You can move the orthotic from shoe to shoe to ensure proper support at all times.
If you do buy an orthotic with a neuroma pad incorporated into it, I would highly recommend the Powerstep Pinnacle Plus orthotics.
These inserts are great because the neuroma pad is already inside the insert. Also, the insert has a firm but comfortable arch in it to help with arch support.
Depending on how much you walk, these inserts last around 6 months to 1 year. You will know when it’s time to replace them because the arch on the insert will start to collapse.
Also, remember to remove your shoe liners before placing the inserts in your shoes!
Pro tip: Since the orthotic will take pressure away from the ball of your feet, it may also help to prevent any calluses in your forefoot from becoming thicker.
- Corticosteroid injections
There is evidence to suggest that corticosteroid reduces pain associated with Morton’s neuroma (5).
The steroid is usually mixed with a local anesthetic to reduce pain and inflammation of the nerve.
You can resume your activities normally after receiving a steroid shot.
- Physical therapy
Physical Therapy can help with the mobilization of the joints and soft tissues in your foot and thus reduce pain in the nerve.
Surgery
If the neuroma pain continues despite conservative treatment, your doctor will recommend excising the nerve.
3) Tarsal Tunnel Syndrome
Some people may experience entrapment of the tibial nerve along the inside of their ankle. This is called “tarsal tunnel syndrome”.
Causes
- Flatfoot structure
When you have a flat foot structure, you likely roll inwards as you walk. This will then cause impingement of the tibial nerve, thus causing pain.
- Varicose Veins
As mentioned before, anything that causes pressure along the tibial nerve can cause tarsal tunnel.
Varicose veins are often prominent along the inside of the ankle. This in itself can pinch the foot nerve and cause shooting pain to extend into the toes.
- Soft tissue mass
Soft tissue masses are commonly seen in the ankle, such as fatty tumors (lipomas) and ganglion cysts. These masses can pinch the tibial nerve and cause tunnel syndrome.
Symptoms
- Burning and tingling pain on the inside of the foot and ankle
- Stabbing pain that starts at the ankle and extends towards your toes
To read more about stabbing foot pain on the inside of your foot, check out the article here.
Diagnosis
Your doctor will perform a physical exam and assess your foot structure. He/she will tap on your tibial nerve and see if you experience shooting pain. This is called a “Tinel’s test” and confirms tarsal tunnel syndrome.
Your doctor will order x-rays of your foot to assess your foot structure. An MRI may also be ordered to rule out any soft tissue masses that may be pinching the nerve.
Occasionally, a Nerve Conduction Test may be ordered to identify nerve impingement.
Treatment
Non-Surgical
Your doctor will want to fix the biomechanics of your foot with orthotics to help alleviate pressure from the nerve. This can be done with over-the-counter arch support or prescription custom orthotic.
Steroid injections and anti-inflammatory medications can be useful to reduce inflammation. This will in turn reduce pain and swelling (6).
Surgical
If conservative therapy fails, your doctor will recommend surgery to decompress the tarsal tunnel to alleviate nerve impingement.
4) Neuritis On The Top Of Your Foot can cause foot pain
The nerves that branch on the top of your foot (deep peroneal nerve and superficial peroneal nerve) are fairly superficial. If you have arthritic spurs on the top of your feet, your shoe gear can cause compression of the nerves over the spurs and cause shooting pain.
Symptoms
- Burning pain on the top of your foot (especially in the top middle portion of your foot)
- Stabbing pain on the top of the foot that occurs with walking
- Tingling pain on the top of your foot
Diagnosis
Your doctor will order x-rays to assess whether arthritis is visible in the joints of the midfoot.
Your doctor will also tap on the different nerves on the top of your foot to try to reproduce the pain.
This is a Tinel’s test and normally is not painful in patients who have no nerve impingement.
Treatment
Non-Surgical
Anything that causes compression on the top of the foot should be removed. Try not to get any shallow shoes that may cause pressure on the top of your foot.
This can cause the nerve pain on the top of your foot to worsen due to compression.
If you have shoes with shoelaces, try skipping tying the laces over the bone spur and the nerve. This can help provide some relief.
You can also obtain Aspercreme with Lidocaine 4% online. This is a fairly effective numbing cream that you can rub on the top of your foot to help with the pain.
Corticosteroid injections are quite beneficial for both arthritis as well as nerve pain. It can help reduce pain and inflammation in both the joints and the nerve. You can resume your activities like normal after the steroid injection.
Surgery
If your symptoms worsen, your doctor may recommend surgery. Your doctor may be able to surgically remove the bone spurs which will over time help with the nerve pain that you experience on the top of your foot (7). You can walk immediately after the surgery.
5) Baxter’s Neuritis
If you experience sharp pain in your heel, it could be “Baxter’s neuritis”. This is often confused with plantar fasciitis because symptoms may be similar.
Make sure to check out this article on the different causes of heel pain here.
In some people, Baxter’s nerve, which is a branch of the lateral plantar nerve on the bottom of your heel, can become pinched.
Certain conditions like an overpronated flatfoot, obesity, and a history of plantar fasciitis can contribute to the impingement of Baxter’s nerve.
Symptoms
- Sharp pain in the heel
- Burning pain in the heel that isn’t relieved with rest
Diagnosis
Your doctor will perform a physical exam and order an x-ray to assess your foot structure. An MRI may be ordered which can help identify Baxter’s nerve as well.
Treatment
Non-Surgical
Anti-inflammatory medications can help to reduce pain associated with Baxter’s neuritis. A corticosteroid injection can also be beneficial to help reduce pain and inflammation in the nerve.
Your doctor may also recommend custom orthotics to change how you walk and alleviate pain in the heel.
Cushion heel cups such as Tuli’s heel cups can be beneficial because they cushion the heel and reduce pain while walking.
Surgical
In some cases, your doctor may choose to decompress Baxter’s nerve surgically to help alleviate symptoms. If there’s a chance that your heel spur may be pinching on the nerve, it will be removed as well.
6) Joplin’s Neuritis
If you experience sharp or burning pain on the inside of your great toe joint, you may be experiencing “Joplin’s neuritis”.
Joplin’s neuritis is an irritation of the branch of the medial plantar nerve that occurs on the inside of the great toe.
Joplin’s neuritis is usually due to entrapment of the medial plantar nerve (6).
Say for instance you have a large bunion, you may experience sharp pain on the inside of your great toe when wearing certain shoes.
Narrow shoe gear that is constrictive can cause Joplin’s neuritis.
Symptoms
- Sharp pain on the inside of your great toe
- Burning pain on the inside of the foot that extends into the toe
- Numbness and tingling on the inside of the great toe joint
Diagnosis
Your doctor can diagnose Joplin’s neuritis with a clinical exam. He/she may tap on the nerve and if you experience pain, it’s considered a positive Tinel’s test.
Your doctor will also obtain x-rays to determine what is causing the nerve to be pinched. Bunions and masses could be pressing on the nerve and causing symptoms.
Treatment
Non-Surgical options
- Wider shoes
Make sure you wear shoes that are wide enough so that they do not impinge and cause nerve problems. Go to a running shoe store, and get the length and width of your feet measured to make sure the shoe is a good fit.
- Manual massages to the great toe joint
Mobilizing both the soft tissue and the nerve can help decrease symptoms.
- Anti-inflammatory medications such as Motrin
Anti-inflammatories are beneficial to help reduce pain and swelling in the joint area.
- Corticosteroid injections
Corticosteroid injections directly into the nerve can be beneficial to help decrease pain.
7) Superficial Peroneal Nerve Impingement in the foot
The superficial peroneal nerve is the nerve that runs on the front of the ankle into the top outer portion of your foot. The nerve branches and goes into your toes. This nerve can be compressed or injured and cause pain.
The superficial peroneal nerve can become traumatized if you sustain an ankle sprain or an ankle fracture. You may experience irritation to the nerve due to injury and swelling in the leg/ankle.
The superficial peroneal nerve may also become pinched in some people who participate in activities such as dance, running and other sports.
Symptoms
Burning, shooting pain in the front of your ankle and the top of your foot.
Diagnosis
Your doctor will obtain your history and perform a physical exam. Tinel’s test may be positive. Occasionally, Nerve Conduction Testing may be ordered to check for impingement.
Treatment
Over-the-counter Aspercreme with Lidocaine 4% cream and Lidocaine 5% prescription patches may be beneficial to help reduce the sharp pain on the top of your foot and ankle.
Steroid injections can be very beneficial to reduce pain in the ankle as well.
In rare cases, surgery can be performed to decompress the nerve if symptoms are severe.
8) Complex Regional Pain Syndrome (CRPS)
Complex regional pain syndrome is a condition where you may experience chronic pain and foot problems secondary to trauma, or nerve injury (8).
CRPS type 1 can occur secondary to tissue injury in the foot, and CRPS type 2 can occur secondary to specific nerve injury in the foot.
This can occur due to the body’s increased response to pain. The exact mechanism of CRPS is still unclear.
Symptoms
- Severe, sharp, burning foot pain
Pain may be severe even with light touch to the foot
- Skin changes in the foot
Skin color changes may occur due to CRPS. You may notice a blue, purple, or red discoloration of the skin
- Temperature changes in the foot
One foot may be warmer or colder than the other
- Swelling in the foot
Swelling in the foot that stays persistent
- Muscle weakness
Muscle weakness can occur in the foot that is affected by CRPS. The pain associated with CRPS can cause you to walk less, making muscle weakness even worse.
Diagnosis
Your doctor will perform a physical exam and obtain an X-ray to assess your foot. Your doctor may also want to obtain an NCV/EMG to assess the nerves and muscles.
Treatment
CRPS is complex and can be difficult to treat. Your doctor may recommend physical therapy to help reduce pain and improve mobility in your foot.
Topical pain medication such as Lidocaine can be beneficial to help reduce pain.
Your doctor may also suggest that you go to the pain clinic to be assessed by physicians who specialize in chronic pain.
If your pain is severe, a sympathetic nerve block may be helpful. There is where medication is injected into the spine to block nerve pain in the foot.
9) Other Conditions That Can Cause Nerve Pain on the Foot
Certain health conditions can cause nerve pain in the feet.
Vitamin B12 deficiency
Vitamin B12 is an essential nutrient. If you are deficient in vitamin B12, the protective myelin sheath of the nerves can become damaged. This can cause neuropathy symptoms in the feet.
Inherited disorders
Inherited disorders like Charcot Marie Tooth can cause neuropathy in the feet due to changes in the genes that occur that lead to damage of the nerves.
Spinal problems
Nerve pain can be caused by spinal problems such as spinal stenosis and herniated discs.
Spinal stenosis occurs when the spinal canal narrows, which puts pressure on the nerves that run through it.
Herniated discs, on the other hand, happen when the outer layer of the spinal disc ruptures, causing the inner gel-like material to leak out and press against the surrounding nerves, resulting in pain and discomfort.
Alcohol-induced neuropathy
Excessive alcohol use over time can be toxic to nerve tissue and cause nerve pain on the foot.
Medications
Certain medications, like some chemotherapy drugs, can cause neuropathy in the feet.
Infections
Some infections like Hepatitis B, Hepatitis C, and HIV can cause nerve damage and nerve pain in the feet.
Autoimmune disease
Certain autoimmune diseases such as Rheumatoid arthritis, Sjogren’s syndrome, Multiple Sclerosis, and Lupus can cause nerve pain on the foot. This occurs because your immune system attacks your tissues, causing nerve damage.
Idiopathic neuropathy
In some people, the cause of nerve pain on the foot may be unknown. This is called “Idiopathic neuropathy”.
Idiopathic neuropathy affects 5-8 million Americans (10). It’s important to speak to your doctor if you experience sudden and progressive nerve pain so your doctor can rule out the commonly known causes of neuropathy, as well as treat your symptoms.
Pain management for people who suffer from neuropathy requires a team of specialists (9). This includes your Family physician, Podiatrist, Pain Management Physician, and Neurologist. All of these specialists can offer their expertise to come up with the best solution for you.
Conclusion
In conclusion, chronic nerve pain in the foot can significantly affect one’s health and overall wellbeing. However, it’s crucial to understand that there are various medical services and treatments available to help manage this condition. It’s important to follow the advice and guidance of healthcare professionals, who can provide education, medicine and other therapies to alleviate pain medically.
Don’t suffer in silence, reach out to your doctor and take the necessary steps to improve your quality of life.
Related article: Why Is Neuropathy Worse at Night: Causes and Treatment for Nerve Pain
References
- Volmer-Thole, M., & Lobmann, R. (2016). Neuropathy and diabetic foot syndrome. International journal of molecular sciences, 17(6), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926450/
- Ennion, L., & Hijmans, J. (2019). Improving vibration perception in a patient with type 2 diabetes and sensory peripheral neuropathy. The South African Journal of physiotherapy, 75(1), 602. https://doi.org/10.4102/sajp.v75i1.602.
- Bates, D., Schultheis, B. C., Hanes, M. C., Jolly, S. M., Chakravarthy, K. V., Deer, T. R., Levy, R. M., & Hunter, C. W. (2019). A Comprehensive Algorithm for Management of Neuropathic Pain. Pain medicine (Malden, Mass.), 20(Suppl 1), S2–S12. https://doi.org/10.1093/pm/pnz075
- Groninger, H., & Schisler, R. E. (2012). Topical capsaicin for neuropathic pain #255. Journal of palliative medicine, 15(8), 946–947. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462404/
- Matthews, B.G., Hurn, S.E., Harding, M.P. et al. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton’s neuroma): a systematic review and meta-analysis. J Foot Ankle Res 12, 12 (2019). https://doi.org/10.1186/s13047-019-0320-7
- McCrory, P., Bell, S., & Bradshaw, C. (2002). Nerve entrapments of the lower leg, ankle, and foot in sport. Sports Medicine, 32(6), 371-391.https://www.researchgate.net/profile/Paul-
- Bawa V, Fallat LM, Kish JP. Surgical Outcomes for Resection of the Dorsal Exostosis of the Metatarsocuneiform Joints. J Foot Ankle Surg. 2016 May-Jun;55(3):496-9. https://pubmed.ncbi.nlm.nih.gov/26872522/
- Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practicing clinician. British journal of anesthesia, 123(2), e424–e433. https://doi.org/10.1016/j.bja.2019.03.030
- Tavee, J., & Zhou, L. (2009). Small fiber neuropathy: a burning problem. Cleve Clin J Med, 76(5), 297-305. https://northwestern.cloud-cme.com/assets/northwestern/pdf/Small%20Fiber%20Neuropathy_10.25.2017.pdf
- Singer, M. A., Vernino, S. A., & Wolfe, G. I. (2012). Idiopathic neuropathy: new paradigms, new promise. Journal of the Peripheral Nervous System, 17, 43-49.https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/j.1529-8027.2012.00395.x
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