Numbness and Tingling in the Hands and Feet

Numbness and tingling usually represents either a neurological or vascular problem.  

The nerves supplying the arms and hands originate in the cervical spine whereas those innervating the feet come from the lumbar and sacral spine. Nerve injuries are the result of compression/entrapment, traction, penetrating wounds and blunt trauma.  Knowledge of the course of a nerve and its distribution is essential to making an accurate diagnosis. 

Vascular problems can usually be diagnosed by evaluating for adequate perfusion by evaluating pulses, signs of decreased perfusion, and capillary refill.  Neurologic diseases may also cause symptoms, such as Guillain-Barre syndrome.  Regardless of the cause, if symptoms are progressing, consider prompt referral before the patient becomes too debilitated to care for or protect themselves.

The radial and ulnar arteries supply blood to the hand.  Compromise of these vessels at any point during their course may produce hand tingling.  Chronic vascular insufficiency can sometimes be manifested by loss of hair.  Nerve problems will produce tingling in a distribution characteristic of the involved nerve(s)

Differential diagnosis of hand tingling

• Vascular compromise

• Neurologic causes

  • C Spine impingement

  • Peripheral nerve entrapment

  • Metabolic causes (rare) such as hypothyroidism, diabetes

• Thoracic outlet syndrome

Physical exam:

• Vascular:

  • Radial pulse

  • Capillary refill- normal is less than 2 seconds

  • Compression of subclavian artery may cause neurologic and vascular symptoms that can affect the upper limb (thoracic outlet syndrome).  Adson test – take wrist radial pulse; abduct, extend, and externally rotate the arm.  Patient takes deep breath and turns head toward the arm tested.  + if pulse is disappears or is diminished.

• Neurologic

  • Radicular signs

  • Check Cervical dermatomes:

    • C6 thumb, C7 middle finger, C8 little finger

  • Spurling’s test – axial pressure applied to top of head, head is then rotated and extended so that chin is pointing towards a shoulder extended.  Pain on side of  compression suggests nerve impingement from herniated disk or foraminal narrowing

  •   Peripheral nerve entrapment signs

  • Median nerve runs under carpal tunnel

    • Motor - thumb pinch

    • Sensory - distal radial aspect of index finger

    • Phalen’s – hyperflexion of wrist causes symptoms in less than 45 seconds

    • Tinel’s –tapping nerve reproduces symptoms

  •  Ulnar nerve – runs through cubital tunnel in elbow into Guyon’s canal in wrist between the pisiform bone and hook of hamate

    • Motor - abduction little finger, grip strength

    • Sensory - distal ulnar aspect little finger

  •  Radial nerve – radial nerve wraps around humerus and down dorsum of forearm

    • Often compressed at radial tunnel just distal to elbow compressing the Posterior interosseous nerve (PIN) branch

    • May also be injured during humerus fracture.

    • Motor - extend the wrist, therefor will have a wrist drop

    • Sensory - dorsal web space between thumb and index finger

Lower Extremities

As with hand tingling, foot tingling is also usually due to a vascular or nerve lesion. The distribution, rapidity of onset, and associated symptoms will help determine the cause.

Differential diagnosis:

• Vascular compromise due to direct trauma, compartment syndrome, anatomic abnormality, or metabolic disease (diabetes, peripheral vascular disease)

• Nerve damage or impingement for many of the same reasons as above, also think of disk disease

Physical exam.  

Determine the distribution of the symptoms

Dermatomes: Sensation

• L4 medial malleolus

• L5 dorsum of foot

• S1 lateral malleolus

Peripheral nerves:

• Posterior tibial nerve

  • Crosses behind the medial malleolus to enter the tarsal tunnel where it may be entrapped

  • Sensation to sole of foot, get intermittent pain, paresthesias or burning in the sole; may get worse with walking  

  • motor (S1: foot plantar flexors)  

• Peroneal nerve  - deep peroneal nerve – goes through lateral compartment,

  • sensation to 1st web space

  • motor to foot dorsiflexors and extensors

When do you order tests:

If there is pain out of proportion to injury, painful range of motion, and parasthesia, consider compartment syndrome and get compartment pressures.  Surgical emergency – if not treated can lose complete function of nerve and muscles in compartment, may have systemic complications too.

Electromyography (EMG) and nerve conduction (NC) studies are further tests to help establish diagnosis.  Need symptoms/nerve damage for 4 weeks to have positive test.  

X-rays suggested if h/o trauma or to rule out a mass or bone deformity

Treatment

• Depends on the underlying condition

• If nerve compression from overuse, treat with NSAIDs, splinting/padding, avoid aggravating activity, loose fitting clothing (e.g. shoes in TTS)

When to refer?

• If symptoms persist  or worsen -  may need a steroid injection (CTS, TTS) or surgical release/decompression.  Always be cautious about compartment syndrome.

• If vascular cause suspected, patient will need referral for further vascular studies such as US or angiogram.

Are there other causes for numbness and tingling?

Yes, many different conditions may cause nerve and/or vascular damage such as:

• Diabetes – nerve damage usually a late complication

• Alcohol – involves both sensory and motor (probable thiamine deficiency)

• Guillian-Barre – usually follows a viral URI, immunization or surgery (virus may trigger an  abnormal immune response).  Get progressive weakness, may get respiratory failure and require prolonged ventilator support

• Hereditary disorders

• Enzymatic – beriberi (thiamine deficiency), pellagra (niacin deficiency)

• Renal (uremic) neuropathy

• Amyloidosis– progressive loss of autonomic function, symmetric pain

• Porphyria

• Infections (AIDS, Lyme disease herpes zoster, diptheria, Leprosy)

• Systemic (carcinoma, collagen vascular diseases)

• Toxins (arsenic, lead, mercury, thallium, gold to treat RA, chemotherapeutic agents, organophosphates, Vitamin B intoxication)

If the patient does not respond to treatment or if signs and symptoms are worsening, refer/Medevac based on the severity and rapidity of the complaints.

Chris Polkoski, MS, PA-C and Scott D. Flinn, MD

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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