It's wintertime; many people attribute their cold feet to the frigid temperatures outside. Although cold extremities may be due to the body's response to external temperature, they could also be a sign of malnutrition and systemic diseases that a podiatrist should identify and address in conjunction with another medical specialist. A thorough history and physical examination are necessary to pinpoint the cause of their pathology. Symptoms may include weakness and pain in the extremities, sensitivity to cold, color changes to skin, and numbness during warming periods. As podiatrists, we need to be aware of the many factors that may lead to cold feet in our patients and therefore dictate their course of treatment.

Vascular disease affects many people, especially those with a history of smoking or diabetes. Patients have narrowed or calcified blood vessels that cause poor blood outflow to the extremities. This may result in cold toes or feet. A medical history and clinical examination consisting of a thorough vascular exam are necessary. Symptoms may include pain at rest, a few steps or blocks upon ambulation, and cold feet that do not resolve with warming. Patients should have noninvasive studies to check the flow status in their lower extremities to assess the patency of the major arteries of the foot. A vascular referral might be needed, as well as an angiogram to determine the location of the occlusion(s). Untreated peripheral vascular disease can lead to ischemic changes and gangrene with chances of limb loss.

Another vascular phenomenon causing symptoms of cold feet is Raynaud's (disease and syndrome). In addition, trauma, cold, stress, or scleroderma can lead to vasospasms constricting vessels flowing to the feet. Symptoms include extreme sensitivity to cold temperatures and possible changes in color, such as blue or purple tones in the cold and redness when warmed. Treatment is warming the feet with socks or placing yourself in a room with higher temperatures. Some patients may also take more drastic lifestyle changes by relocating to states with warmer weather.

 Other culprits causing cold feet symptoms could be related to medications such as beta-blockers, migraine medications, and pseudoephedrine. These medications can cause constriction of blood vessels causing symptoms of cold feet.

           Peripheral neuropathy is a condition of degeneration of axons of distal nerves causing numbness or perceived coldness to the area once supplied by the nerve. Although common in patients with diabetes, it can also be seen in conditions such as alcoholism, malnutrition, hypothyroidism, and chemotherapy. Vitamin deficiency, such as that of B12 and folate, can cause demyelination of nerves leading to peripheral neuropathy. In addition, iron deficiency anemia, which is an iron deficiency, and therefore hemoglobin production, directly affects the amount of oxygen reaching tissues in the body. Thus, an appropriate amount of blood may not reach the far extremities and toes, causing symptoms of cold toes.

           Hypothyroidism, the 2nd most prevalent endocrine disorder after diabetes, is another culprit of cold feet. Patients unable to create sufficient thyroid hormone cannot thermoregulate their body temperature. Other systemic diseases that can lead to cold feet are hyperlipidemia, which damages and constricts blood flow through inflammation and atherosclerosis of arteries, and diabetes, which causes glycosylation and calcification. Therefore, it is crucial to get regular blood work and follow up with a primary care physician who can provide the appropriate referrals.   

            Symptoms of cold feet, while a cause of normal reaction of the body to decreasing external temperatures, should not be dismissed. They may indicate underlying vascular, systemic, or endocrine diseases that a specialist should further evaluate. Podiatrists are crucial in identifying factors that can lead to cold feet, so a multidisciplinary approach is recommended across multiple subspecialties.

Contributors:

• Jane Pontious, DPM Clinical Professor, Dept. of Podiatric Surgery TUSPM
• Kushkaran Kaur, DPM, MS

1. Kersting, Jonas, et al. "Guideline-Oriented Therapy of Lower Extremity Peripheral Artery Disease (PAD)–Current Data and Perspectives." RöFo-Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren. Vol. 191. No. 04. © Georg Thieme Verlag KG, 2019.
2. Crockett, David, and Daniel Bilsker. "Bringing the feet in from the cold: Thermal biofeedback training of foot-warming in Raynaud's syndrome." Biofeedback and Self-regulation 9 (1984): 431-438.