Advances in preventing and treating diabetic neuropathy
By Claire Kowalick
For people living with Type 2 diabetes, one complication often goes unnoticed until it is too late — peripheral nerve dysfunction, or diabetic neuropathy.
Type 2 diabetes, which is often related to obesity, can lead to both nerve damage and peripheral vascular disease due to chronic high glucose levels. Over time, these elevated glucose levels cause oxidative stress, inflammation and vascular injury, putting the feet at particular risk due to their longer nerves and reduced blood flow. In many patients, neuropathy arises eight to 12 years after the onset of diabetes.
“Amputation does not have to be the inevitable outcome of Type 2 diabetes. At every stage, we have opportunities to intervene, to prevent neuropathy from starting, to prevent ulcers from forming and to stop ulcers from progressing to amputation.”
– Lee C. Rogers, DPM, associate clinical professor and chief of the Division of Podiatry
Pain: The ‘gift nobody wants’
For some patients, diabetic neuropathy brings severe nerve pain, tingling or shooting sensations. Painful neuropathy can last up to three years as nerves degenerate. Unfortunately, the most common outcome after the nerves die off is numbness.
While the absence of pain might seem like a relief, it presents a far greater danger, said Lee C. Rogers, DPM, associate clinical professor and chief of the Division of Podiatry at The University of Texas at San Antonio’s Health Science Center.
“Numbness is the major risk factor in diabetic foot complications,” he said.
Without the ability to feel pain, people can unknowingly injure their feet during everyday activities like walking. Repetitive stress leads to calluses, blisters and eventually ulcerations, open sores that are slow to heal and prone to infection. When people lose sensation partially or entirely, they may not notice injuries that can escalate into ulcers and infections. About 15% to 25% of people with diabetes will develop a foot ulcer during their lifetime, and of those, roughly 20% may eventually require amputation.
The danger of neuropathy and its connection to limb ulceration was first recognized by surgeon Paul Brand, CBE, who discovered the link while working with leprosy patients in India. Brand famously called pain “the gift nobody wants,” recognizing that pain serves as the body’s natural defense against further injury.
For individuals with diabetes who have lost this protective mechanism, even poorly fitting footwear can initiate a domino effect of damage. In fact, Rogers said some patients with neuropathy choose shoes that are half a size too small because they need more pressure to feel like the shoes fit properly, inadvertently creating more pressure points that can lead to foot injury.
Annual foot screenings recommended
Because of these hidden dangers, early detection is critical. The American Diabetes Association recommends annual foot screenings for people diagnosed with Type 2 diabetes. During these assessments, a healthcare provider generates a risk score estimating a patient’s likelihood of developing a foot ulcer within the next year. The most widely used assessment is The University of Texas Foot Risk Classification, first described at the Health Science Center in 1996 and now adapted by several national and international organizations.
“Just like you get your eyes checked every year, you should have your feet checked,” said Rogers.
“Our ultimate goal is prevention, but when needed, we have an exceptional team ready to provide life-changing care.”
– Monica Verduzco-Gutierrez, MD, professor and chair of the Department of Rehabilitation Medicine
Prevention is protection
Once neuropathy is detected, preventive measures may include prescription footwear designed to reduce high pressure points, more frequent podiatric visits and, in some cases, surgeries to correct deformities like bunions or hammertoes that increase pressure when walking.
One of the most promising recent advances in ulcer prevention is remote patient monitoring, a field in which the university’s Health Science Center is setting the pace. Technologies that measure foot skin temperatures, like smart mats, Bluetooth-connected insoles and handheld contact thermometers allow patients to track subtle changes in foot temperature, which can be an early indicator of inflammation and is the first sign of a new ulcer forming.
Studies show these devices can predict ulcer formation up to a month before it becomes visible. With early warning of foot temperature differences, patients can seek medical attention before ulcers develop, allowing specialists to intervene and prevent more serious complications.
“When you have diabetes, it’s what you can’t feel that will hurt you. If you cannot feel pain, we have to find other ways to detect trauma,” said Rogers.
Risk of recurrence
Even after an ulcer heals, infection or ulcer recurrence remains a significant risk. Skin with scar tissue is less resilient and biomechanical issues such as arthritis can concentrate pressure on specific areas of the foot, making ulcer recurrence more likely.
“The risk of recurrence after a first ulcer is 30-40% within the first year,” said Rogers.
In addition to preventive technology, new treatments are improving wound healing. Advanced skin-substitute grafts bioengineered from human cells, processed animal tissues or synthetic scaffolding offer promising options to replace damaged skin and promote healing.
While scientists continue to search for ways to reverse neuropathy itself, no evidence-based treatments currently exist to restore protective sensation once it is lost, making prevention even more critical. Newer treatments, such as GLP-1 receptor agonists are helping patients achieve better glucose control, while ongoing research is exploring non-opioid medications and specialized pain clinic interventions to help manage neuropathic and post-amputation pain. This summer, UT San Antonio’s Multispecialty and Research Hospital became the first in Texas to approve the use of the newly FDA-approved non-opioid pain medicine, suzetrigine (brand name Journavx), as a first-line treatment for managing post-surgical pain following orthopedic and podiatric procedures.
“Amputation does not have to be the inevitable outcome of Type 2 diabetes,” Rogers said. “At every stage, we have opportunities to intervene, to prevent neuropathy from starting, to prevent ulcers from forming and to stop ulcers from progressing to amputation.”
When prevention is not enough
When prevention is not enough, some patients may face the difficult reality of amputation. If a foot or limb infection spreads or becomes systemic, a multidisciplinary team at UT Health San Antonio — the institution’s comprehensive health system — steps in, including podiatrists, vascular surgeons, rehabilitation specialists and prosthetic experts, said Monica Verduzco-Gutierrez, MD, professor and chair of the university’s Department of Rehabilitation Medicine.
If an amputation becomes necessary, the care team works to preserve as much function as possible, often beginning with toe or partial foot amputations before considering below-knee procedures. Following amputation, patients are fitted for prosthetics tailored to their activity level and function. Certified prosthetic orthotic specialists collaborate with physical medicine and rehabilitation teams to ensure each patient receives a device that maximizes independence while being easy to use, even for those with physical limitations.
Physical therapists help patients gradually build tolerance to wearing their prosthetics, starting with short daily wear times and progressing toward full-day use. Psychological support is another critical part of care, as many patients struggle with body image, phantom pain and the emotional toll of their new reality.
With advances in technology, education and team-based care, patients have more tools than ever to protect their feet and their quality of life, even when complications arise, said Verduzco-Gutierrez.
“Our ultimate goal is prevention, but when needed, we have an exceptional team ready to provide life-changing care.”
