My Feet are Burning and Pins Are Sticking

I recently saw the following question:

My feet feel like something is stuck to the bottom of them all the time. They burn sometimes and sometimes they feel like pins are sticking in them. What can I take to make them feel better? I have type 2 diabetes, and am taking Glucophage.

My reply:

Sounds like you probably have diabetic nerve damage. This presents with numbness, dysesthesias (odd and somewhat painful sensations), and/or pain in the feet. This form of neuropathy is frequently called peripheral neuropathy (or more precisely, distal symmetric sensory polyneuropathy). It is common in people with diabetes, and is usually attributed to long-term lack of control of diabetes - but it may also have additional causative factors including (among others) alcohol abuse, neurotoxic medications, and vitamin B12 deficiency. These should be investigated, and if present, treated. If no other factors are found, then the standard treatments for peripheral neuropathy should be tried: tighten up the control of diabetes, topical creams such as capsaicin, and oral medications including antidepressants, anticonvulsants and opiods. Some newer drugs are specifically approved for treatment of diabetic nerve pain, including Cymbalta (duloxetine), Lyrica (pregabalin), and Nucynta ER (tapentadol).

You don't mention anything about your diabetes control. If your A1C is elevated, you should increase the intensity of your diabetes management -- a larger dose of Glucophage (metformin) if you are not on maximal dose, or add a second drug to help get the BG levels down to normal. If you are not already working on a weight-control meal plan, you should start one.

What type of medical specialist should be involved with the care of diabetic neuropathy? I think that any physician interested in chronic pain could coordinate figuring out the diagnosis and treatment. A knowledgeable general physician such as a Family Practice or Internal Medicine specialist might be a good choice. As diabetes specialists frequently see patients with diabetic nerve pain, they too are usually up-to-date on what to do. But, please note, some endocrinologists don’t deal with diabetes much, and would be little better than asking your next-door neighbor for advice.

Should you be referred to a “pain specialist”? Depends. Medically-trained physicians specializing in neurologic disorders (called neurologists) would certainly be a good choice. If there’s a vascular component to your difficulties (due to narrowing of blood vessels in the legs), then a vascular surgeon should definitely be consulted. But seeing an anesthesiologist who wants to earn
extra bucks on the side by injecting pain patients with nerve blocks, trigger point injections, and epidural steroids should, IMHO, be avoided like the plague. These folks just don’t have the patience to act comprehensively, working over the long term to control your diabetes, look for other risk factors, and try a second (or third or fourth) treatment modality when an earlier trial doesn’t work out.

As I hint above, it might well be necessary to try different medications to figure out how to best control the pain. And controlling the diabetes as best you can is definitely in order.

Hope this helps!