What are the causes of pins-and-needles (paresthesia) in the hands and legs?

Causes of Pins and Needles (Paresthesia) in Hands and Legs

Pins and needles in the hands and legs most commonly results from peripheral neuropathy, with diabetes being the leading cause in Western populations, followed by entrapment neuropathies (especially carpal tunnel syndrome), vitamin deficiencies (B12, thiamine, vitamin E), alcohol-related nerve damage, and less commonly, immune-mediated conditions like Guillain-Barré syndrome. 1, 2, 3

Primary Etiologic Categories

Metabolic and Endocrine Causes

• Diabetes mellitus is the single most common cause of peripheral neuropathy presenting with distal symmetric polyneuropathy in a "glove and stocking" distribution 1, 4
• Symptoms characteristically worsen at night, causing sleep disturbance, and include burning pain, electrical shock sensations, tingling, and contact pain (allodynia) 4
• Hypothyroidism causes carpal tunnel syndrome and other sensory complaints requiring thyroid function testing in all patients with carpal tunnel syndrome 1
• Acromegaly can produce carpal tunnel syndrome and sensory symptoms 1

Nutritional Deficiencies

• Vitamin B12 deficiency causes impaired proprioception and sensory ataxia due to damage to dorsal columns and peripheral nerves, presenting with balance issues and falls 2
• Vitamin E deficiency is associated with cerebellar atrophy and sensory ataxia 2
• Thiamine deficiency (particularly in alcoholic neuropathy) requires high-dose B-vitamin regimen with parenteral thiamine initially 3

Alcohol-Related Neuropathy

• Total lifetime dose of ethanol is the most important risk factor, followed by duration of alcoholic disease 3
• Absolute alcohol abstinence is the cornerstone of treatment, with favorable prognosis and recovery over several months to years with abstinence 3
• Comprehensive B-vitamin supplementation is essential to address nutritional deficiencies 3

Entrapment Neuropathies

• Carpal tunnel syndrome is the most common cause of acroparesthesia (hand paresthesia), producing weakness of median-innervated muscles (LOAF muscles: lateral two lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis) 5, 6
• Ulnar neuropathy at the elbow requires elbow padding and may need nerve conduction studies 5
• Peroneal nerve injury can occur from external compression, particularly during prolonged surgical procedures or positioning 7

Immune-Mediated and Inflammatory Causes

• Guillain-Barré syndrome presents with rapidly progressive bilateral weakness starting in legs, distal paresthesias, and areflexia, reaching maximum disability within 2 weeks 4
• Sensory variants include Miller Fisher syndrome (ophthalmoplegia, areflexia, ataxia) and pure motor variants 4, 2
• Treatment requires IVIG (0.4 g/kg daily for 5 days) or plasma exchange (200-250 ml/kg for 5 sessions) 4

Medication and Toxin-Induced

• Chemotherapeutic agents (platinum compounds, taxanes) cause dorsal root ganglion damage and sensory axonal neuropathy 2
• Proteasome inhibitors (bortezomib) cause predominantly sensory neuropathy with proprioceptive involvement 2
• Dose reduction or discontinuation of offending agents may be required 2

Critical Red Flags Requiring Urgent Evaluation

Seek immediate assessment if paresthesia is:

• Acute onset (within days) and rapidly progressive 6
• Asymmetric, proximal, or multifocal distribution 6
• Associated with predominant motor weakness or severe dysautonomia 6
• Bilateral facial involvement (rare in Bell's palsy, suggests alternative diagnosis) 4

These features may indicate Guillain-Barré syndrome or vasculitis requiring rapid management 6, 4

Diagnostic Approach

Essential Initial Testing

• Complete blood count to screen for systemic disease 1
• Thyroid function tests mandatory in all patients with carpal tunnel syndrome 1
• Vitamin B12 levels and autoimmune panels for sensory ataxic presentations 2
• Fasting glucose and HbA1c to screen for diabetes 3, 1

Neurophysiological Studies

• Nerve conduction studies confirm peripheral neuropathy diagnosis and localize entrapment sites 5, 2
• Note that nerve conduction studies may be normal with small fiber neuropathy 5
• Electromyography may be needed when nerve conduction studies are inconclusive 1

Specialized Testing When Indicated

• 10-g monofilament testing at multiple plantar sites to assess loss of protective sensation in diabetic patients 3
• Positive Romberg test indicates sensory ataxia from proprioceptive loss 2
• Neuroimaging (MRI) of brain and spinal cord to exclude central causes when clinical features suggest central pathology 2, 8

Management Based on Etiology

Diabetes-Related Neuropathy

• Tight glucose control is the primary intervention 1
• For painful symptoms: tricyclic antidepressants, anticonvulsants (gabapentin, pregabalin), or SNRIs as first-line agents 4
• Capsaicin cream for localized burning pain 1
• Comprehensive foot examination every 6-12 months with specialized therapeutic footwear for those with loss of protective sensation 3

Entrapment Syndromes

• Night splinting for carpal tunnel syndrome 5
• Elbow padding for ulnar neuropathy 5
• Ultrasound-guided steroid injection or surgical release if conservative measures fail 6

Nutritional Deficiencies

• Vitamin B12 supplementation for confirmed deficiency 2
• Thiamine replacement (parenteral initially) with comprehensive B-vitamin supplementation for alcoholic neuropathy 3

Immune-Mediated Causes

• IVIG or plasmapheresis for Guillain-Barré syndrome 4, 2
• Corticosteroids may be considered for certain immune-mediated neuropathies 2

Common Pitfalls to Avoid

• Do not assume diabetes without testing—hypothyroidism, B12 deficiency, and alcohol use are frequently overlooked 1, 2, 3
• Do not rely solely on nerve conduction studies—small fiber neuropathy produces normal studies despite significant symptoms 5
• Do not miss Guillain-Barré syndrome—rapid bilateral progression with areflexia requires urgent treatment within days 4
• Always test thyroid function in carpal tunnel syndrome—this is a mandatory screening test 1
• Screen for diabetes in all alcoholic neuropathy patients, as conditions frequently coexist 3