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Lower Extremity Somatic Effects of Post-Traumatic Stress Disorder

David T. Weiss, DPM, FACFAS
09/08/2025
© 2025 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Podiatry Today or HMP Global, their employees, and affiliates. 

"Trauma is not what happens to you. Trauma is what happens inside you as a result of what happens to you." – Gabor Maté

Post-Traumatic Stress Disorder (PTSD) is widely recognized for its profound impact on mental health. Still, its effects extend beyond psychological boundaries, contributing to symptoms in the lower extremities. Among the myriad of physical manifestations are presentations that podiatrists see often in their practices. This piece aims to introduce the podiatric physician to this complex interplay and enhance awareness of the impact on patients.

The Interplay of PTSD and Physical Symptoms

The intricate relationship between PTSD and physical symptoms can be understood through the lens of the body's integrated response to trauma. The stress hormones released in response to perceived threats prepare the body for immediate action and have long-term effects on various physiological systems. In PTSD, the chronic activation of this stress response can lead to persistent physiological changes, including those affecting the lower extremities.1,2

One notable observation is the delayed normalization of stress hormone levels in PTSD patients after a stressful event.3 This prolonged exposure to high levels of adrenaline and cortisol perpetuates a state of hyperarousal.4-6 It can contribute to the development of conditions like Raynaud's syndrome,7,8 peripheral neuropathy,9-11 idiopathic pain,12,13 and joint pain.14,15 The body's continuous alertness and readiness to respond to threats then take a toll on the musculoskeletal and nervous systems, potentially leading to these chronic pain syndromes.

The Lower Extremity Effects of PTSD

PTSD can have physical manifestations, particularly in the lower extremities. These PTSD symptoms can take various forms. For example, Raynaud's Syndrome may present as pain, numbness, and changes in foot and toe color. Peripheral neuropathy can cause numbness, tingling, and pain. Chronic stress and elevated stress hormones can contribute to nerve damage and increased one’s perception of pain in individuals with PTSD.16-18      

I’ve also observed that idiopathic pain, or pain without a clear cause, often plagues PTSD sufferers, with the nervous system's heightened sensitivity leading to chronic pain experiences. Joint pain is also prevalent, in my experience, inflammatory cytokines released during stress contributing to joint discomfort and stiffness.16-18     

Dermal Manifestations

Post-Traumatic Stress Disorder (PTSD) can also potentially lead to various dermal manifestations in the lower extremities, reflecting both psychological stress and associated physiological responses. These manifestations include inflammatory dermatoses like eczema, psoriasis, and lichen planus, which appear red, scaly, or itchy patches. Stress-related dermatitis, including atopic and contact dermatitis, is also prevalent, showing signs of erythema, scaling, and pruritus. Additionally, PTSD can cause excoriation disorder, leading to visible sores and secondary infections from repetitive skin picking or scratching. Some patients may develop small-vessel vasculitis or purpuric lesions due to stress-induced immune dysregulation, while others experience delayed wound healing, increasing the risk of infections and complications.16-18

The pathophysiological mechanisms behind these manifestations involve neuroendocrine dysregulation. PTSD disrupts the hypothalamic-pituitary-adrenal (HPA) axis and alters cortisol levels, significantly impacting skin integrity and immune responses. Autonomic nervous system dysfunction can lead to altered sweat production and vascular responses, contributing to hyperhidrosis or cold and clammy skin conditions. Chronic stress associated with PTSD elevates levels of inflammatory cytokines, such as interleukins and tumor necrosis factor-alpha (TNF-α), exacerbating inflammatory skin conditions and contributing to skin inflammation and lesions.16-18

Effective management of these dermal manifestations requires a holistic approach, addressing both mental health and dermatological needs. In severe cases, treatments may include appropriate topical applications like corticosteroids, moisturizers, antihistamines, and systemic treatments.16-19 Behavioral therapies, including habit-reversal training and psychotherapy, can help manage skin-picking behaviors and address underlying psychological factors. Collaboration between dermatologists, lower extremity specialists, mental health professionals, and primary care providers is essential for comprehensive care, ensuring both the psychological and dermatological aspects of PTSD are effectively addressed.20-31

More on Collaborative Treatment Strategies

Understanding the relationship between the psychological and physiological aspects of PTSD is essential for developing effective treatment strategies that address the whole person, promoting both mental and physical well-being. By integrating therapies, and the associated qualified professionals, such as CBT,19,32,33 ketamine therapy,34-36 EMDR,37-39  psilocybin,40-42  mindfulness practices,43-45 pharmacological interventions,46-48 and diet49,50 and lifestyle modifications,51 healthcare practitioners can contribute to more comprehensive and effective care for trauma survivors.

Notes on Fibromyalgia

Post-Traumatic Stress Disorder (PTSD) and fibromyalgia share overlapping symptoms and pathophysiological mechanisms, particularly in terms of lower extremity manifestations. Central sensitization is a common link between both conditions, leading to heightened sensitivity to stimuli, allodynia, and hyperalgesia.52-54 Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis exacerbates stress responses, contributing to chronic pain and discomfort in the lower extremities. Neurotransmitter imbalances involving serotonin, norepinephrine, and dopamine further affect pain perception and mood, leading to chronic lower extremity pain, fatigue, and sleep disturbances such as restless legs syndrome (RLS).55-57

Clinically, patients with PTSD and fibromyalgia often report deep, aching pain in the legs, feet, and lower back, coupled with significant fatigue and weakness, making daily activities challenging. Trauma and chronic stress are substantial risk factors for both conditions, with stress-induced dysregulation perpetuating pain and discomfort.58 Ineffective coping mechanisms, such as avoidance behaviors and heightened vigilance, can exacerbate physical and emotional exhaustion, worsening symptoms.59 Research indicates that elevated inflammatory markers, including interleukins and tumor necrosis factor-alpha (TNF-α), are associated with chronic pain in both PTSD and fibromyalgia patients.60,61

Effectively managing these conditions requires a comprehensive, multidisciplinary approach that addresses psychological and physiological aspects. Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and Eye Movement Desensitization and Reprocessing (EMDR) have shown promise in alleviating PTSD symptoms by helping patients develop coping strategies and reducing hyperarousal.62-65 Pharmacological treatments targeting stress hormone modulation and neuropathic pain can relieve symptoms, while lifestyle modifications such as regular physical activity, proper nutrition, and stress management are crucial.66

Stressing the Importance of Awareness and Involvement

Understanding the complex relationship between the psychological and physiological aspects of PTSD is essential for developing effective treatment strategies that address the whole person, promoting both mental and physical well-being. PTSD manifests through a wide range of symptoms, including anxiety, depression, and chronic pain syndromes, necessitating a multifaceted approach to treatment. Therapeutic interventions must target both the mind and body to ensure comprehensive care and improved outcomes for individuals suffering from this debilitating condition.

The physiological dysregulation associated with PTSD underscores the complexity of treating trauma, as it affects various bodily systems and overall health. The psychological impact of trauma is equally significant, as evidenced by the profound changes in behavior and emotional state among PTSD patients. 

Looking ahead, the Weiss Institute has conducted and is conducting several clinical trials to evaluate various therapeutic options, including regenerative therapies, in cohorts of patients with PTSD. By focusing on regenerative medicine and integrating it with psychotherapeutic approaches, the Institute aims to provide clinicians with patients with strong data on comprehensive and effective treatment options for trauma survivors, addressing both their mental and lower extremity physical health needs.

“The body bears the burden: trauma that goes unaddressed can manifest in the body, affecting everything from our immune system to our limbs.” – Bessel van der Kolk MD


Dr. Weiss specializes in Regenerative Medicine of the lower extremity, and is the Medical Director, of the Weiss Institute For Regenerative Medicine. He is the Assistant Fellowship Director at the Virginia Fellowship in Reconstruction, Revision and Limb Preservation since 2019. He is a Fellow of the American College of Foot and Ankle Surgeons.

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