Peripheral Neuropathy

Peripheral neuropathy means the peripheral nerves are damaged.

Peripheral nerves are the cables that leave the spinal cord and run to the skin, muscles and organs. They carry sensation inward and movement commands outward. When they are damaged, sensation becomes faint, distorted or painful, and muscles can weaken.

The longest nerves are affected first. That is why symptoms usually begin in the toes and feet, the furthest point from the spinal cord, and only reach the hands once they have climbed to about the knees. Doctors call this a length-dependent pattern, and it is the pattern of most neuropathy.

Peripheral neuropathy is common. A review of population studies put it at about 2 to 3 in every 100 adults, and at roughly 8 in 100 over the age of 55 in the general-practice study it drew on (Martyn and Hughes, J Neurol Neurosurg Psychiatry, 1997). In Australia, as in most high-income countries, diabetes is the most common identifiable cause.

At CURA Medical Specialists in Drummoyne, Sydney, peripheral neuropathy is assessed by neurologists working alongside the clinical neurophysiologists who perform the nerve tests on-site, so the pattern and the test are read by the same team.

There are three kinds of nerve fibre, and the symptoms depend on which are affected:

• Sensory fibres — numbness, tingling, pain, poor balance
• Motor fibres — weakness, wasting, cramps
• Autonomic fibres — dizziness on standing, sweating changes, bowel and bladder symptoms

The typical course

Sensation fades in the toes first, then the soles, then climbs the shins over months to years. Pain, when present, is burning, stabbing or electric and is worst at rest and at night. Balance suffers because the feet no longer report where they are, so unsteadiness shows up first in the dark or on uneven ground. The hands join in only after the feet, once symptoms have reached about the knees.

Small-fibre neuropathy

Some people have burning pain and altered temperature sense with normal strength, normal reflexes and a normal nerve conduction study. That is because the study tests the large fibres and the pain comes from the small ones. A normal study does not mean nothing is wrong. The diagnosis is made clinically; it can be confirmed by a skin biopsy that counts nerve fibres, available at a small number of specialised centres, where that result would change management. Small-fibre neuropathy has its own cause work-up, with an oral glucose tolerance test high on the list.

Patterns that need a neurologist sooner — or the same day

• Symptoms that are asymmetric — one leg much worse than the other, or patchy areas in different limbs
• Weakness as an early or dominant feature
• Symptoms that begin in the hands, or hands and feet at the same time
• Rapid progression over a few weeks — phone reception today for a same-day assessment; if walking, swallowing or breathing is affected, or it is happening over hours to days, call 000
• Neuropathy alongside unexplained weight loss, rash, fever or joint pain

These patterns raise the chance of an immune, inflammatory or vasculitic neuropathy — the minority of neuropathies where a neurologist’s treatment changes the outcome, and where delay costs nerve.

Finding the cause is the first job, because the treatment follows from it.

Peripheral neuropathy has many causes, and in most people the cause can be identified from the history, the examination and a first tier of blood tests. Diabetes and pre-diabetes are the most common identifiable causes in Australia; vitamin B12 deficiency, alcohol, chemotherapy and other medicines, kidney and thyroid disease, and an abnormal blood protein account for most of the rest. A smaller group have an immune neuropathy such as CIDP or a vasculitic neuropathy, which are treatable and sometimes urgent, and some have an inherited neuropathy. In a sizeable minority no cause is found even after a full work-up; that idiopathic neuropathy is usually slow, sensory and manageable. The causes in more detail:

• Diabetes and pre-diabetes — the most common identifiable cause. About 1.3 million Australians were living with diabetes in 2022–24 (Australian Institute of Health and Welfare), and neuropathy is one of its commonest complications. Impaired glucose tolerance, before diabetes is diagnosed, can also cause it.
• Vitamin B12 deficiency — more common in older adults, in vegan or restricted diets, after stomach surgery, and with long-term metformin or acid-suppressing medicines. Reversible if caught early.
• Alcohol — sustained heavy drinking damages nerves directly and through poor nutrition.
• Medicines — several chemotherapy drugs (platinum agents, taxanes, vincristine, bortezomib), and some antibiotics and heart medicines, among others.
• Kidney and thyroid disease — chronic kidney disease and an underactive thyroid.
• Abnormal blood proteins — a paraprotein (monoclonal gammopathy) found on a blood test can be linked to neuropathy and needs its own assessment.
• Immune neuropathies — chronic inflammatory demyelinating polyneuropathy (CIDP) and related conditions, where the immune system attacks the nerve’s insulating layer. Treatable, and the reason not to assume every neuropathy is “just diabetes”.
• Vasculitic neuropathy — inflammation of the small blood vessels feeding the nerves, often patchy and painful. Urgent.
• Inherited neuropathies — Charcot-Marie-Tooth disease and related conditions, often with high arches, hammer toes and a family history.
• No cause found — in a sizeable minority, a full work-up finds nothing. This is called idiopathic neuropathy. It is usually slow, sensory and manageable.

Numb or painful feet are not always peripheral neuropathy. Part of the neurologist’s job is to make sure we are treating the right problem:

• Lumbar spinal stenosis or a pinched nerve root — leg symptoms that come with back pain, are worse standing or walking and better sitting, or follow one leg from buttock to foot.
• Cervical myelopathy — a narrowed spinal canal in the neck can cause numb hands and unsteady legs together, with brisk reflexes rather than absent ones.
• Entrapment neuropathies — carpal tunnel syndrome at the wrist or tarsal tunnel at the ankle affect one nerve in one limb, not both feet.
• Restless legs syndrome — an urge to move the legs at night, relieved by movement, without numbness.
• Circulation problems — peripheral arterial disease causes calf pain on walking and cold feet rather than tingling.

Treating “neuropathy” that is really spinal stenosis with a nerve-pain tablet will not help, which is why the examination matters as much as the test.

1. The pattern comes first

We ask where the symptoms started, how they have spread, how fast, and whether there is weakness, pain or unsteadiness. We review your medical history, alcohol intake and every medicine you take. The examination covers sensation, strength, reflexes and balance; any additional tests depend on the presentation.

2. Blood tests

For a typical slow, symmetric neuropathy, blood tests are the most useful investigation. The three highest-yield tests, per the American Academy of Neurology’s practice parameter on distal symmetric polyneuropathy (England et al., Neurology, 2009), are blood glucose, vitamin B12 (with a follow-on test such as active B12 or methylmalonic acid when the result is borderline), and serum protein electrophoresis with immunofixation for a paraprotein. If fasting glucose and HbA1c are normal, an oral glucose tolerance test looks for impaired glucose tolerance. In usual practice a full blood count and kidney, liver and thyroid function are checked alongside. Your GP may already have done some of these; bring the results. Further tests depend on what the first tier and the pattern suggest.

3. Nerve conduction studies (NCS) and EMG in Drummoyne, Sydney — when they change the plan

Not every neuropathy needs a nerve study. When the pattern is typical and the cause is already known, a careful examination and blood tests are often enough. A nerve conduction study and EMG are most useful when they would change what we do: to confirm that a neuropathy is really present when the examination is equivocal; to tell whether the damage is to the nerve fibre itself or to its insulating layer, which sets the direction of the whole work-up; and when there is weakness, asymmetry, rapid progression, symptoms beginning in the hands, no cause found, or a question of an immune neuropathy such as CIDP. The study tests the large nerve fibres, so it is normal in small-fibre neuropathy.

At CURA Medical Specialists the study is performed on-site at Drummoyne by our clinical neurophysiologists. NCS uses small electrical pulses on the skin to measure how fast and how strongly signals travel along a nerve. EMG uses a fine needle to record the electrical activity of muscles. Where a muscle or nerve-to-muscle junction problem is suspected, repetitive nerve stimulation and single-fibre EMG are also available on-site. The study usually takes 30 to 60 minutes. Most people describe the pulses as a brief tap or tingle, uncomfortable rather than painful. Details and preparation are on the nerve conduction study page.

4. Imaging — only when the examination points to the spine

An MRI of the neck or lower back is arranged when the history or examination suggests the spinal cord or nerve roots rather than the peripheral nerves. It is not a routine part of a neuropathy work-up.

5. Further tests, when needed

Depending on the pattern, we may arrange a lumbar puncture, which can support a diagnosis of CIDP though it is not required for it, genetic testing for a suspected inherited neuropathy, or referral for specialised tests we do not perform on-site. We will explain why before any of these are ordered.

The right treatment depends on the cause, the pattern, and what is troubling you most: pain, numbness, weakness or falls.

Treat the cause where there is one

• Diabetes and pre-diabetes — better glucose control slows progression; it rarely reverses established damage. This is shared work with your GP or endocrinologist.
• B12 deficiency — replacement, usually by injection at first, then tablets. Early cases can recover.
• Alcohol — stopping drinking, with nutritional support, usually halts the damage.
• Medicines — where a medicine is the likely cause, we discuss with the prescribing doctor whether it can be changed.
• Thyroid and kidney disease — treating the underlying condition.

Immune neuropathies — where a neurologist’s treatment changes the outcome

CIDP responds to treatment that suppresses the immune attack. For CIDP the first-line options are intravenous immunoglobulin, corticosteroids and plasma exchange, and subcutaneous immunoglobulin is an option for maintenance; for related immune neuropathies the choice depends on the specific diagnosis, and some respond to immunoglobulin but not to the others. Most people with CIDP respond to a first-line treatment; some need a second. In Australia, immunoglobulin is authorised through BloodSTAR against the National Blood Authority’s criteria and given through a hospital infusion service, with an objective response required at review. We make the diagnosis, arrange the treatment, and supervise it over time. Early treatment protects nerve that cannot be regrown later.

Neuropathic pain — the medicines that work, and what the PBS covers

We choose based on your other conditions, and we tell you which medicine is subsidised before you fill the script. The first-line medicines for nerve pain in Australia are old, well-established drugs that work by damping the nerve’s abnormal signalling, not as ordinary painkillers, and each takes weeks at a steady dose to judge. What the PBS covers, as at the September 2026 schedule:

• Amitriptyline and nortriptyline (tricyclic antidepressants) — unrestricted PBS benefits, so an ordinary PBS script applies, although their use for nerve pain is outside their registered indication.
• Pregabalin — PBS-subsidised for neuropathic pain that has not responded to other treatment.
• Duloxetine — TGA-approved for diabetic nerve pain, but its PBS listing is for depression, so a private prescription may apply.
• Gabapentin — PBS-listed for epilepsy, not pain, so a private prescription may apply.
• Opioids are not recommended for long-term neuropathic pain (Australian Prescriber). For localised pain, topical treatments can help.

Focal nerve problems

Where a single nerve is trapped or irritated as well as, or instead of, a generalised neuropathy — carpal tunnel syndrome is the common example — ultrasound-guided nerve injections are performed at CURA for selected cases. Whether one is relevant depends on the diagnosis.

Numbness, balance and falls

• Physiotherapy for strength and balance, and a review of footwear and home hazards, reduce falls. A walking aid is sometimes the single most protective step.
• Foot care matters. With numb feet you can injure yourself without knowing. Check your feet daily, wear well-fitting shoes, and see a podiatrist if you have diabetes.
• Occupational therapy for hand symptoms that affect daily tasks.

Nerves regrow slowly, at roughly a millimetre a day, so recovery where it happens is measured in months, not weeks. Most people with neuropathy remain active. What helps:

• Exercise. Walking, cycling, swimming and resistance training are safe and improve balance, mood and, in diabetes, glucose control. Avoid barefoot walking if your feet are numb.
• Sleep. Night pain often responds to the medicines above, taken in the evening.
• Driving. Numb feet can affect pedal control. Tell us if you have noticed this; we will advise honestly.
• Review. Neuropathy is followed over time. If it stops behaving as expected — faster progression, new weakness, new asymmetry — it is reassessed, because the cause can change.

• healthdirect — Peripheral neuropathy (Australian Government) — healthdirect.gov.au
• Better Health Channel — Peripheral neuropathy (Victorian Government) — betterhealth.vic.gov.au
• Diabetes Australia — Nerve damage (neuropathy) — diabetesaustralia.com.au
• Australian Prescriber — Neuropathic pain: definition and drug therapy — australianprescriber.tg.org.au
• MBS Online (Australian Government Department of Health) — mbsonline.gov.au (current item descriptors and rebates)