Neuropathy typically announces itself with tingling, numbness, or burning sensations that start in your toes or fingertips and gradually spread inward over weeks or months. The pattern is one of the most telling clues: symptoms that affect both feet (or both hands) symmetrically, often described as a “stocking and glove” distribution, point strongly toward peripheral neuropathy rather than a pinched nerve or other localized problem.
Sensory Symptoms That Come First
For most people, the earliest signs involve changes in sensation. Tingling is the most common starting point, a pins-and-needles feeling that may be constant or come and go. Numbness follows or arrives alongside it. You might notice you can’t feel the coldness of a drink in your hand, or you can’t detect the texture of carpet under your bare feet. These changes tend to creep upward slowly, from toes toward the ankles, from fingertips toward the wrists.
Pain is another hallmark, but it doesn’t always behave like normal pain. Neuropathic pain can make ordinary sensations hurt. A bedsheet brushing your feet might feel sharp or burning, a phenomenon called allodynia. Or a mildly painful stimulus, like bumping your toe, might feel far more intense than it should. Many people describe the pain as burning, stabbing, or electric. It often worsens at night.
Balance problems can also signal neuropathy, even before you notice numbness. Your nerves constantly send positional information to your brain about where your feet and hands are in space. When those signals weaken, you may feel unsteady, especially in the dark or on uneven surfaces. Dropping things or feeling clumsy with buttons and zippers can be another subtle early sign.
How It Differs From a Pinched Nerve
Neuropathy and radiculopathy (a compressed spinal nerve root) can both cause tingling and pain, but they behave differently. Neuropathy typically affects both sides of the body in that symmetrical stocking-and-glove pattern and isn’t triggered by particular body positions. Radiculopathy usually travels down one arm or one leg along a specific path, and it often flares when you bend, cough, sneeze, or sit in certain positions. If your symptoms shoot from your lower back down one leg, or from your neck into one arm, that’s more consistent with a nerve root problem than peripheral neuropathy.
Signs Beyond Tingling and Pain
Neuropathy doesn’t only affect sensation. If motor nerves are involved, you may notice muscle weakness, cramping, or visible twitching. This tends to start in the feet and lower legs, making it harder to lift the front of your foot while walking, or in the hands, weakening your grip.
A third category, autonomic neuropathy, affects nerves that control involuntary body functions. These symptoms are easy to overlook or attribute to something else entirely:
- Lightheadedness when standing up, caused by nerves that can no longer adjust your blood pressure quickly enough when you change positions.
- Digestive problems like bloating, early fullness, nausea, constipation, or diarrhea, sometimes alternating between the two. In some cases, the stomach empties too slowly, a condition called gastroparesis.
- Bladder changes, including difficulty sensing when your bladder is full, trouble emptying it completely, or leaking urine.
- Sweating abnormalities, such as excessive sweating at night or while eating, or patches of skin that don’t sweat at all, making it hard for your body to regulate temperature.
- Sexual dysfunction, including erectile difficulty in men and reduced arousal or sensation in women.
- Slow-adjusting pupils, which can make it harder to see when entering a dark room or when driving at night with oncoming headlights.
If you have diabetes, autonomic neuropathy can also blunt your ability to feel the warning signs of low blood sugar, like shakiness and sweating. This is called hypoglycemia unawareness and is particularly dangerous because it removes your early alert system.
What Happens During a Neuropathy Exam
If you bring these symptoms to a doctor, the evaluation usually starts with a physical exam focused on your feet and hands. Two simple bedside tests are especially informative.
The monofilament test uses a thin nylon fiber pressed against the sole of your foot with just enough force to make it bend. You close your eyes and say when you feel it. Feeling fewer than eight out of ten touches indicates reduced protective sensation. The tuning fork test places a vibrating 128 Hz fork on your big toe. A healthy young adult should feel the vibration for at least 15 seconds. Feeling it for less than 10 seconds is abnormal at any age.
Your doctor will also check your reflexes, which tend to diminish broadly with neuropathy (particularly at the ankles first), and test muscle strength in your feet and hands.
Nerve Conduction and EMG Testing
If the exam suggests neuropathy, electrodiagnostic testing can confirm it and help characterize what’s happening inside the nerve. Nerve conduction studies deliver small electrical pulses through the skin over a nerve and measure how fast the signal travels and how strong it is when it arrives. Slow conduction speed suggests damage to the nerve’s insulating sheath (myelin). Reduced signal strength points to loss of the nerve fibers themselves.
An EMG, or needle electrode exam, involves inserting a thin needle into a muscle to record its electrical activity at rest and during contraction. Abnormal spontaneous electrical activity at rest signals that muscle fibers have lost their nerve supply. Together, these two tests help determine the type of neuropathy, its severity, and whether it’s progressing.
One limitation: standard nerve conduction studies only measure large nerve fibers. If your symptoms involve mainly burning pain and temperature sensitivity, you may have small fiber neuropathy, which these tests can miss entirely. In that case, a skin biopsy from the lower leg can count the density of tiny nerve endings in the skin and compare the result to age- and sex-matched norms. A reduced count confirms the diagnosis.
Blood Tests That Identify the Cause
Finding neuropathy is only half the picture. Identifying its cause is what guides treatment. A standard initial workup includes blood tests for fasting blood sugar (the most common culprit by far), vitamin B12 levels, thyroid function, kidney and liver markers, and signs of inflammation. If diabetes is suspected but fasting glucose is normal, a glucose tolerance test or hemoglobin A1c can catch prediabetes, which is itself a frequent cause of neuropathy that many people don’t realize they have.
Additional testing depends on the clinical picture. Unusual patterns, rapid progression, or signs of demyelination on nerve conduction studies may prompt tests for autoimmune conditions or abnormal blood proteins. But for the majority of people, the cause turns out to be diabetes, prediabetes, B12 deficiency, thyroid disease, or alcohol use.
Self-Screening You Can Do at Home
The Michigan Neuropathy Screening Instrument is a validated questionnaire originally designed for diabetic neuropathy but useful as a general gauge. It asks 15 yes-or-no questions about symptoms like numbness, burning, prickling, muscle cramps, sensitivity to touch, and trouble sensing water temperature with your feet. A higher score out of 13 countable points suggests more neuropathic involvement. It’s not a diagnosis, but if you score high, it’s a strong reason to bring the topic up with your doctor and request a focused exam.
Even without a formal questionnaire, a few patterns should prompt evaluation: symmetrical tingling or numbness that started in your feet and has been spreading, burning pain in your soles that worsens at night, difficulty feeling injuries on your feet, or unexplained balance problems. If any of these have been creeping in gradually over weeks or months, that timeline and pattern are characteristic of neuropathy rather than a one-time injury or passing issue.