What is burning feet syndrome?

Burning Feet Syndrome: Diagnosis and Management

Burning feet syndrome is characterized by burning pain, often accompanied by sensations of tingling, numbness, and warmth in the feet, which may significantly impact quality of life and can be caused by various underlying conditions including peripheral neuropathy, erythromelalgia, or nutritional deficiencies.

Clinical Presentation

• Patients typically describe burning pain in the feet, which may be accompanied by uncomfortable tingling (paresthesia), numbness, and subjective sensations of altered temperature perception 1
• The burning sensation is often more severe at night, frequently resulting in sleep disturbance and subsequent fatigue 1
• Symptoms may progress from the feet up the limbs and occasionally involve the upper limbs, particularly the hands 1
• Despite distressing subjective symptoms, physical examination often reveals minimal objective findings 2

Common Etiologies

Diabetic Peripheral Neuropathy

• Most common cause of burning feet in clinical practice 1
• Symptoms result from small fiber dysfunction causing pain and dysesthesia 1
• Often presents with burning, tingling sensations in a "stocking" distribution 1
• May be accompanied by loss of protective sensation, increasing risk for foot ulceration 1

Erythromelalgia

• Characterized by episodic burning pain associated with redness and warmth of the extremities 1
• Episodes often triggered by physical activity and exposure to warm temperatures 1
• Pain is characteristically relieved by cooling the affected areas 1
• May be primary (idiopathic or inherited) or secondary to underlying conditions like myeloproliferative disorders 1

Other Causes

• Nutritional deficiencies (particularly B vitamins) as historically noted in the "Burning Feet Syndrome" observed in malnourished prisoners of war 3
• Small fiber neuropathy from various etiologies 4
• HCV-related extrahepatic manifestations 1
• Peripheral nerve compression or entrapment syndromes 1
• Medication side effects 1

Diagnostic Approach

• Assessment should include a careful history focusing on pain characteristics, aggravating/relieving factors, and associated symptoms 1
• Physical examination should evaluate:
  • Small-fiber function: pinprick and temperature sensation 1
  • Large-fiber function: vibration sensation using a 128-Hz tuning fork 1
  • Protective sensation: 10-g monofilament testing 1
  • Skin appearance: look for erythema, warmth, or other changes 1
• Laboratory testing to identify underlying causes:
  • Glucose metabolism (fasting glucose, HbA1c) 1
  • Vitamin levels (B12, folate) 3
  • Complete blood count (to assess for myeloproliferative disorders) 1
  • Hepatitis C testing when suspected 1
• Electrophysiological testing or referral to a neurologist may be necessary in atypical cases 1

Management

Treatment of Underlying Cause

• Optimize glucose control in diabetic neuropathy to prevent progression 1
• Correct nutritional deficiencies if identified 3
• For secondary erythromelalgia due to myeloproliferative disorders, aspirin is first-line therapy 1

Pharmacologic Management

• First-line medications for neuropathic pain:
  • Pregabalin, duloxetine, or gabapentin are recommended initial treatments 1
  • Tricyclic antidepressants (e.g., amitriptyline) may be effective 1
• Second-line approaches include:
  • Opioids such as tramadol, morphine, or oxycodone for refractory cases 1
  • Topical treatments may provide localized relief with fewer systemic side effects 1

Non-Pharmacologic Approaches

• For erythromelalgia:
  • Avoid triggers such as excessive heat and vigorous exercise 1
  • Elevate extremities during symptoms 1
  • Use cooling measures safely (limit ice/cold water immersion to 10 minutes, 4 times daily) 1
• For diabetic neuropathy:
  • Regular foot inspection and proper footwear to prevent complications 1
  • Maintain activity as tolerated to preserve function 1

Special Considerations

• Patients with burning feet often experience significant sleep disturbance, anxiety, and depression that require appropriate management 1
• Avoid excessive cooling methods (ice water immersion, powerful fans) as these may lead to tissue damage, ulcerations, and worsening symptoms 1
• For patients with severe, refractory symptoms, referral to a multidisciplinary pain management center should be considered 1
• Monitor for development of foot ulcers in patients with diabetic neuropathy and loss of protective sensation 1

Common Pitfalls

• Failing to identify treatable underlying causes before initiating symptomatic therapy 1
• Overlooking the diagnosis when physical examination reveals minimal objective findings despite significant symptoms 2
• Inadequate pain control leading to sleep disturbance, which can worsen pain perception and quality of life 1
• Patients using excessive cooling methods that may cause tissue damage 1