Dr. Elliot Johnson

The Numbness Is How Diabetics Lose Feet

If you are on Gabapentin, Lyrica, or a similar nerve-pain medication and the feeling in your feet has started to fade — the floor going muffled, the numbness climbing past the toes — you have somewhere between two and four years before that numbness could become the kind that does not come back. I am a vascular and limb-salvage surgeon with 21 years of practice. I have spent the last decade removing toes, feet, and legs from people who started exactly where you are now, while telling almost none of them what was actually coming. I am writing this letter to break that silence. People on long-term Gabapentin, Lyrica, Amitriptyline, and Cymbalta experience spreading numbness, loss of protective sensation, and slow-healing skin on the feet at rates that almost no primary-care visit tracks — because the pain score on the intake form is the only outcome the appointment is measuring. Almost none of them are told that the medication "managing" their nerve pain does nothing to restore the blood supply that is starving the nerve in the first place. They are told the pill is "treating the neuropathy." That phrase, in isolation, is one of the most expensive half-truths in the way we treat feet. I'm Dr. Elliot Johnson. I'm a vascular and limb-salvage surgeon who spent years watching patients cycle through nerve-pain prescriptions without telling them what was about to happen to the feet underneath. When the burning and the numbness started in my own feet at 54, I finally understood something I had never explained to a single neuropathy patient. The pain is not the disease. The tingling is not the disease. The numbness is not the disease. They are all symptoms of one underlying problem — the starved circulation and dying nerve fibers that the burning was screaming about and that your nerve-pain medication is quieting on paper while doing nothing to feed the nerve. Almost every drug added to a neuropathy protocol mutes the next symptom while the underlying starvation continues to progress. I have treated thousands of feet in my career. I have seen what happens at year two on Gabapentin. Year four. Year six. Year nine. And I have seen what almost no one documents properly, because the appointments are too short and nobody is asking the question that matters: can you still feel the floor. The 62-year-old. On Gabapentin for six years. Pain score "managed," dose bumped twice. His primary-care doctor was satisfied. The burning at night had faded — which everyone read as good news — but it faded because the fibers carrying that signal were dying, not healing. The numbness that replaced it climbed from his toes to his mid-foot over three years, and no one charted it, because he never volunteered it and no one asked. He stepped on a thumbtack in his garage in year six and finished the task he was doing before he noticed the blood. That thumbtack became a wound. The wound would not close. I met him in year seven, in my clinic, deciding how much of his foot we could save. The 58-year-old. Diabetic, diagnosed at 49. On Lyrica for the last several years. Pain "controlled." The cold feet — a documented sign of failing circulation — had been there for years, and he'd been told to wear thicker socks. Started noticing he couldn't feel the pedals properly around year five. His doctor called it expected progression and raised the dose. Then added a cream for the patches that still burned. Three years later he was in my office with an ulcer on the ball of his foot he swore had "just appeared," though it had clearly been open for weeks. His numbness had been the warning at year four. The muffled floor had been the warning at year five. By the time I saw the wound, the circulation to that foot had been failing silently for the better part of a decade. The 67-year-old. Not diabetic. "Idiopathic," her chart said — nobody knew the cause. On Amitriptyline, then Gabapentin, then both. Every visit measured her pain and adjusted her pills. Not one measured whether she could feel a 10-gram filament pressed against her sole — the test that takes ninety seconds and predicts exactly who ends up on my table. She failed that test badly the first time anyone finally ran it, in the emergency room, the night an infection from a blister she never felt had already reached the bone. I see these people after the cascade has run. They do not complain about their feet in the early years. They are grateful the burning has quieted and that someone is "managing" the pain. But I know what they lost. They had years to address the starved circulation that was killing the nerve in the first place. Years to reopen the blood supply while the fibers could still recover. Years to stay off my table. Their feet had been screaming the warning the entire time — and then, worse, had gone quiet. The prescriptions just turned down the volume, one symptom at a time, while the starvation underneath compounded. What almost no one explains to a person on a nerve-pain medication whose feet are going numb is this. The pain you feel is the downstream result of how well or poorly the tiny blood vessels feeding your nerve fibers are delivering oxygen. A healthy microcirculation keeps those fibers alive, and they keep sending honest signals — including the signal that says "there is a stone in your shoe, move." When that blood supply is choked off, by years of high blood sugar, by aging, by poor circulation, the fibers begin to suffocate. Some misfire on the way out — that is the burning, the shocks, the shattered glass. Others fall silent — that is the numbness, the muffled floor, the wound you never feel. Your doctor's response to the pain is to prescribe a nerve-pain drug. Each works differently. Gabapentin and Lyrica quiet the overexcited pain signal in the nervous system. The burning drops. But they do nothing to the blood supply feeding the fiber. The signal is muted while the fiber keeps starving. And when the burning fades, everyone mistakes the silence for improvement — when often it is the fiber dying, not recovering. Amitriptyline and the other nerve-pain antidepressants dampen how the pain is processed centrally. Again the number on the pain chart improves. Again the vessel and the fiber are untouched. The numbing creams work at the surface for an hour. The bloodstream is never involved, and the nerve underneath is never reached. Each of these moves the pain score. None of them restores the circulation. All of them leave the fiber to keep dying while the appointment records a win. The burning you have been medicating is not the warning. The numbness that replaced it is the louder warning. The loss of the ability to feel a coin under your foot is the warning before the catastrophe. And the wound that opens on a foot that can no longer feel it — the wound that will not heal because the same starved circulation cannot deliver what healing requires — is the disease finally arriving where I can see it. The published research on this is not obscure. Loss of protective sensation is the single strongest predictor of foot ulceration and amputation — it precedes the wound, and the wound precedes the operation, by years. The pain score is what the medication moves. The sensation and the circulation are what determine whether you keep your foot. Your numbness is not embarrassing, and it is not "just getting older." It is your early-warning system, and the warning is louder than the pain score your doctor is tracking. I was not going to walk the road I had watched thousands of my own patients walk. And I needed a path that actually reached the mechanism instead of muting one more symptom. I tried what neuropathy patients try. Lifestyle changes. Tighter blood sugar. Walking. Weight off. It helped at the edges, but the numbness held. Standard supplements. Alpha lipoic acid. Benfotiamine. High-dose B12. The whole neuropathy-forum list. It did not move the floor back under my feet. My pain was manageable. But my feet stayed cold. The numbness held its ground and, on the bad months, gained a little. The pills had moved the pain while the circulation kept failing. But I kept circling something that made no sense in standard practice. Starved nerve fibers, in the early-to-moderate stage, can recover — if you restore the blood supply and switch the repair signal back on. The circulation research had shown this for years. Almost no one in primary care or neurology was applying it to feet. So why was I not applying it to my own? It was late — past eleven — after a long day of clinic and one amputation I have never stopped thinking about. I couldn't sleep. The numbness in my own soles was worse that week. I was reading through research on peripheral circulation and nerve repair. Not looking for anything in particular. Just tired. I found the work on photobiomodulation — red and near-infrared light — and nitric oxide. Two precise wavelengths of light, 660nm red and 850nm near-infrared, drive the body's own nitric oxide, the molecule that tells a blood vessel to open. Open the vessel and the blood follows. Feed the starved fiber and, at the same wavelengths, stimulate Nerve Growth Factor — the body's own signal to rebuild a damaged nerve ending. The pathway did not depend on the pain-signaling the drugs were blunting. It reached the thing underneath the drugs entirely: the blood supply, and the nerve it was supposed to feed. The mechanism didn't just quiet the symptom. It addressed the starvation. Restore the circulation, switch the repair signal on, and in the early-to-moderate window the fiber can come back. Louis Ignarro, Robert Furchgott, and Ferid Murad won the Nobel Prize in 1998 for the discovery of nitric oxide as the signal that opens every blood vessel in the body. The entire chain neuropathy breaks. I sat there past midnight staring at the diagram. Gabapentin was quieting my pain signal while doing nothing for the blood supply. A stronger dose would have quieted it more and starved the fiber just the same. The pill addressed the alarm. It never once addressed the fire. Photobiomodulation went straight at the fire. Open the circulation. Repair the nerve. The two things a starved fiber actually needs, at the two wavelengths the research actually used. I have been a surgeon for 21 years. And I had never connected clinical red-light therapy to the feet I was amputating. The shared mechanism was never part of any surgical or neurology curriculum I sat through. Past midnight, I went looking for a device that delivered those exact wavelengths correctly. What I learned during that search is something every person with neuropathy needs to know. The wavelengths have to be right, and they have to reach the tissue. Most consumer gadgets that call themselves "red light" are heat lamps or novelty massagers — the wrong wavelengths, or too weak to penetrate past the skin, or aimed at the surface where the pain is instead of the depth where the nerve lives. A warm glow that feels nice and does nothing. For the light to reach the fibers and the vessels that feed them, it has to deliver both wavelengths at once — 660nm at the surface for circulation and inflammation, 850nm penetrating deep to the nerve itself — at clinical intensity, wrapped directly around the foot. I found one that was built right. Nouvera Neurosoothe. The two clinical wavelengths the published research actually uses — 660nm red and 850nm near-infrared — the same ones the professional clinics charge thousands a course to deliver. In a wearable wrap you use on your own couch. No heat-lamp gimmick. No proprietary fairy tale. The mechanism the research studied, in a format you can put on your feet for thirty minutes a night. I started that week. Thirty minutes every evening, wrapped around both feet. Week one. The first thing back was warmth. My feet, always cold, warmed from the inside for the first time in longer than I could remember. Week two. I slept through the night twice — the burning that had been surfacing at 2 a.m. stayed down. Week four. Standing in the shower one morning, I felt the water on the soles of my feet the way I had a decade earlier. Not pressure. Water. I had not known that was gone until it came back. Week eight. The filament test — the same one I run on my patients. Six months earlier I would have failed points on my own sole. That morning I felt every one. My circulation markers had improved. The floor was under my feet again. I went back to a colleague, a podiatrist I refer my worst cases to, for a sensation exam and a look at my flow. He ran the filament. Checked his notes from before. "Elliot. What did you do?" I explained the photobiomodulation. The nitric oxide pathway. The way it sat entirely outside the pain-drugs, reaching the circulation and the nerve instead. He was quiet for a moment. "I have a waiting room full of people I'm sending to wound care and vascular. If this is reproducible..." "The mechanism is real." He started recommending it to his neuropathy patients before their feet reached my table. I am not writing this letter because I am against nerve-pain medication. If the burning is unbearable, these drugs have a place, and you should not stop anything without talking to your doctor. Quieting pain you cannot sleep through is not nothing. But nerve-pain medication does not fix what is starving your nerve. It moves the pain score while the circulation keeps failing and the numbness keeps climbing — first the toes, then the mid-foot, then the day you cannot feel a wound open on your own skin. It does not lower your risk of that wound to zero. It hides the alarm while the fire spreads. Your numbness is not failing you. Your fading sensation is not failing you. They are warning you. I think about what I almost did. I almost accepted the numbness as the price of "managing" the pain, almost let my own feet climb the same ladder I'd watched take so many others, one dose increase at a time, until the day the ladder ends on a table like mine. Eight weeks. That is how long it took for the warmth to come back, the burning at night to quiet, the sensation to return to my soles, and my own filament test to come back clean — thirty minutes a night, wrapped around my feet, while I read. Nouvera Neurosoothe is a fraction of the cost of one month of the pills that fogged my patients' heads, and it comes with a 90-day money-back guarantee. Use it daily. If the warmth, the sleep, the sensation, and the feeling of the floor under your feet do not measurably improve, send it back in any condition for a full refund. — Dr. Elliot Johnson, MD Vascular & Limb-Salvage Surgeon, 21 years Practicing physician P.S. — Give it 60 to 90 days. Track the warmth in your feet. Track how you sleep. Track whether you can feel the floor when you stand up in the morning, and whether you notice the small things — the seam of a sock, the pebble in a shoe — the moment they're there. If the trend lines do not move, send it back. The upside is the version of you that never learns what the inside of a wound-care center smells like. P.P.S. — You are not too late yet. Your nerve-pain medication is doing what it was designed to do for your pain score. Your circulation is not. The window where a starved fiber can still recover is the early-to-moderate one — the one you are most likely in right now, and the one that closes quietly. Open the circulation now, while the fiber can still come back, before the numbness becomes the permanent kind and the first wound arrives that you never feel.