What Peripheral Neuropathy Feels Like
Peripheral neuropathy typically presents with burning sensations, tingling, numbness, and sharp electric shock-like pains that start in the toes and progress proximally, characteristically worsening at night and often causing severe sleep disturbance. 1
Primary Sensory Symptoms
The sensory experience depends on which nerve fiber types are damaged:
Small Fiber Involvement (Most Common Early)
- Burning pain in the feet, often described as "burning feet syndrome" 1
- Prickling or stinging sensations that are constant or intermittent 1
- Sharp, stabbing, electric shock-like pains that come in waves 1
- Dysesthesias (unpleasant abnormal sensations) including tingling 1
- Allodynia (pain from normally non-painful stimuli like light touch or bedsheets) 1
- Painful sensations such as burning in hands and feet in a characteristic pattern 2
Large Fiber Involvement (Later Stage)
- Numbness progressing from toes upward in a "stocking and glove" distribution 1, 3
- Loss of vibration sense and proprioception 1, 2
- Sensory ataxia (unsteadiness due to loss of position sense) 4
- Cramps in the affected limbs 1
Temporal Pattern and Distribution
The symptoms follow a predictable pattern:
- Distal and symmetrical onset, beginning in the longest nerve fibers (toes first) 1, 5
- Length-dependent progression, moving proximally over time from feet toward knees, then hands 5, 3
- Nocturnal exacerbation is characteristic, with pain severely worsening at night 1
- Bilateral and symmetrical in most cases, affecting both sides equally 1, 6
Impact on Daily Function
The sensory disturbances cause significant functional impairment:
- Severe sleep deprivation from constant nighttime pain, leading to persistent tiredness 1
- Reduction in daily activities due to pain and discomfort during the day 1
- Depression and anxiety in over two-thirds of patients with moderate to severe symptoms 1
- Sleep disturbances occur in over 95% of patients with painful peripheral neuropathy 1
Motor and Autonomic Features
Beyond sensory symptoms, patients may experience:
- Distal weakness in advanced cases, though less common than sensory symptoms 1, 5
- Restless legs syndrome as an expression of small fiber involvement 1
- Orthostatic hypotension (dizziness upon standing) from autonomic fiber damage 1
- Dry, cracked skin in the extremities from sudomotor dysfunction 1
Clinical Pitfalls
Important caveats to recognize:
- Up to 50% of peripheral neuropathy may be asymptomatic, requiring physical examination to detect 1
- Symptoms may wax and wane over years, though they typically progress 1
- Small fiber damage often precedes large fiber damage, so normal nerve conduction studies don't rule out neuropathy 1, 4
- 12.5% of patients never report symptoms to their doctor, and 39% never receive treatment despite significant pain 1