Diabetic peripheral neuropathy affects roughly half of people with long-standing diabetes and is a leading driver of foot ulceration and amputation. Medications can ease neuropathic pain in some patients, but none reverses the underlying nerve damage. Against this background, lower-extremity nerve decompression surgery has attracted interest as a procedure that might relieve pain, restore protective sensation, and reduce ulcer risk. The evidence for it is more contested than its advocates suggest, and it is worth examining carefully.
The Rationale for Decompression
The hypothesis behind decompression is that chronically swollen, metabolically stressed nerves become vulnerable to compression at anatomical tunnels, such as the tarsal tunnel at the ankle, where the tibial nerve passes beneath the flexor retinaculum. Surgeons who perform the procedure propose that releasing these sites adds a compressive “second hit” to the diabetic nerve injury and that relieving it can improve function. A 2025 narrative review by Best in Medical Research Archives describes the approach as controversial but potentially useful for pain, quality of life, and protective sensation, which could in turn lower ulcer and amputation risk. Importantly, that review frames these benefits as potential rather than established.
What Pooled Analyses Show
A 2022 systematic review and meta-analysis by Fadel and colleagues in Plastic and Reconstructive Surgery Global Open pooled 21 studies involving 2,169 patients. Among the 16 observational studies, decompression was associated with significant improvement in visual analog scale pain scores and two-point discrimination, and with a significantly lower risk of ulcers and lower-limb amputation. Tarsal tunnel release showed the largest pain reduction and the lowest ulcer risk ratio (0.04, 95% CI 0.00–0.48).
The five randomized controlled trials in the same analysis told a different story. Pain, two-point discrimination, and nerve conduction velocity showed no significant improvement, although each outcome rested on only two studies. The authors themselves called for higher-quality randomized trials.
An earlier structured review by Albers and Jacobson (2018, Diabetes, Metabolic Syndrome and Obesity) reached a cautious conclusion. Of 23 studies, eight assessed pain, and all reported substantial relief after surgery. However, the one double-blind randomized trial found improvement in the sham-surgery leg comparable to that in the decompressed leg. The reviewers judged the data insufficient to recommend decompression for painful neuropathy, while noting that ulcer-prevention findings looked more favourable, with lower ulcer incidence than in the contralateral foot that was only borderline significant.
Evidence From a Sham-Controlled Trial
The most rigorous test to date is the randomized, placebo surgery-controlled trial by Rozen and colleagues, published in Annals of Surgery in 2024. Adults with painful lower-extremity neuropathy were randomized 2:1 to surgery or observation, and surgical patients had one leg decompressed and the other receiving sham surgery. At 12 months, both surgical groups reported significantly lower pain than observation controls (mean difference −4.46), but the decompressed and sham legs improved equally. At the later follow-up of roughly 56 months, pain remained lower in surgical patients than in controls, and decompressed legs had a modestly lower mean pain score than sham legs (mean difference 1.57). The authors concluded that the data do not provide definitive evidence of benefit and acknowledged that part of the effect may be placebo-related.
This pattern matters clinically. A large improvement in both operated and sham legs suggests that expectation, attention, and other non-specific effects contribute substantially to reported pain relief in unblinded studies. It also illustrates why uncontrolled case series, which dominate the literature, tend to overestimate benefit.
Interpreting the Evidence
Several limitations constrain interpretation. Most favourable data come from observational studies, often from a small number of surgical centres, with high risk of bias and non-randomized comparison between operated and non-operated limbs. Patient selection is another unresolved issue: whether benefit is confined to people who have a superimposed focal nerve compression, such as a positive Tinel sign, rather than diffuse neuropathy alone, has not been settled. Ulcer and amputation outcomes require long follow-up and large samples, which existing randomized trials lack. For these reasons, major diabetic foot guidelines continue to emphasize established prevention measures, including regular risk screening, footwear, offloading, and glycemic and vascular management.
Conclusion
Nerve decompression for diabetic neuropathy remains an investigational approach. Observational pooled data suggest reduced pain, ulceration, and amputation, but randomized and sham-controlled evidence shows substantial improvement in sham-treated limbs and no definitive proof of benefit. The Cochrane review of Chaudhry and colleagues (2008), which predates this literature, likewise concluded that the role of decompressive surgery was unproven, and subsequent trials have narrowed rather than resolved that uncertainty. Key priorities are larger blinded trials with validated outcomes, clear criteria for patient selection, and long-term ulcer and amputation endpoints.
References
- Rozen SM, et al. Effect of lower extremity nerve decompression in patients with painful diabetic peripheral neuropathy: the Diabetic Neuropathy Nerve Decompression Randomized Observation Group and Placebo Surgery-Controlled Clinical Trial. Annals of Surgery. 2024.
- Fadel ZT, Imran WM, Azhar T. Lower extremity nerve decompression for diabetic peripheral neuropathy: a systematic review and meta-analysis. Plastic and Reconstructive Surgery Global Open. 2022;10(8):e4478.
- Albers JW, Jacobson R. Decompression nerve surgery for diabetic neuropathy: a structured review of published clinical trials. Diabetes, Metabolic Syndrome and Obesity. 2018;11:493–514.
- Best TJ. Surgical decompression in the management of lower extremity diabetic peripheral neuropathy: a narrative review. Medical Research Archives. 2025;13(8).
- Chaudhry V, Russell J, Belzberg A. Decompressive surgery of lower limbs for symmetrical diabetic peripheral neuropathy. Cochrane Database of Systematic Reviews. 2008;(3).
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