Burning feet at night: causes, red flags and when to get it checked

Burning pain in the feet at rest, especially at night when there are fewer distractions and the feet are warm under covers, usually comes from thin pain-carrying nerve fibres that are damaged or irritable. It often begins in the toes and spreads upward in a sock-like pattern.

• Diabetes or prediabetes: the most common cause of painful neuropathy, sometimes present before diabetes is diagnosed.

• Vitamin B12 deficiency, particularly in people taking metformin or acid-suppressing medicines, vegans and older adults.

• Alcohol-related nerve damage and poor nutrition.

• Athlete foot and other skin conditions causing burning and itching between the toes.

• Underactive thyroid and kidney disease.

• Medicines such as some chemotherapy drugs, statins in rare cases, nitrofurantoin and amiodarone.

• Peripheral arterial disease, causing burning rest pain in cold, pale feet, often relieved by hanging the feet down.

• Erythromelalgia (burning with redness and heat relieved by cooling), small-fibre neuropathy from autoimmune disease, and, rarely, inherited causes or heavy-metal toxicity.

Rapid progression, leg weakness, a foot sore, colour change, coldness, severe pain at rest, loss of sensation, and sudden onset warrant faster assessment.

• Call 999 or go to A&E: sudden cold, white or blue foot with severe pain; spreading weakness in the legs.

• Same-day GP: a foot ulcer or wound, redness spreading up the leg, or signs of infection, especially with diabetes.

• GP within a week or two: progressive burning that disturbs sleep, or numbness.

• Routine GP: burning feet without other symptoms that you would like to understand.

Questions will cover when the burning is worst, whether it is relieved by cold or movement, diabetes, alcohol, diet, medicines and family history. Examination includes the skin and nails, foot pulses and temperature, light touch, pinprick and vibration sensation, ankle reflexes and a diabetic foot check if relevant.

• Blood tests: HbA1c or glucose, B12 and folate, thyroid, kidney and liver function, and full blood count.

• Ankle-brachial pressure index or arterial Doppler: if circulation is suspected.

• Nerve conduction studies: normal in pure small-fibre neuropathy, but they exclude large-fibre involvement.

• Skin biopsy for small-fibre density: used in specialist centres for unexplained cases.

Keep feet cool and dry, wear breathable footwear, check feet daily, and keep blood sugar in range if you have diabetes. Cutting alcohol helps. Cool compresses and a fan may ease night-time burning. Neuropathic pain responds to specific medicines prescribed by a doctor rather than ordinary painkillers.

NHS care begins with a GP, with podiatry, diabetes services or neurology as needed. Private neurology, podiatry and nerve testing can be arranged directly.