02/21/2026
We say “comfort” all the time in clinic, but for someone with peripheral neuropathy, comfort is a misleading metric. If protective sensation is diminished, the absence of pain doesn’t equal the absence of pressure. It just means the alarm system isn’t working.
I see this weekly. A patient proudly tells me, “These are the most comfortable shoes I’ve ever had.” Then we pull them off and there’s a red line across the dorsal PIPJ or a pre-ulcerative callus under the 1st met head. The shoe feels great because it’s soft and forgiving, but it’s too short, too narrow, or collapsing medially. The problem isn’t that patients are making bad decisions. It’s that they’re making decisions without reliable feedback.
That 1–2 cm toe box clearance sounds simple, yet when you actually measure it in clinic, you realize how many people are walking around in shoes a full size too small. And the narrow issue is huge. We’re asking neuropathic patients with hammertoes, bunions, and midfoot collapse to fit into fashion sneakers built on slim lasts.
The rocker sole point is important too. Patients gravitate toward pillowy cushioning because it “feels” protective. But cushioning without structure doesn’t offload pressure. In many cases, a firmer, more stable sole with appropriate rocker geometry does more to reduce peak plantar pressures than another layer of foam ever will.
And the sandal conversation… especially in warm climates, that’s a tough one. The combination of neuropathy and unprotected toes is something we underestimate at our own risk.
The big takeaway for me is this: we can’t outsource shoe assessment to patient perception. If sensation is impaired, then objective evaluation has to replace subjective comfort. Measuring length. Checking width. Inspecting wear patterns. Looking for pressure points. We really do have to be the external sensory system.
Great reminder that “comfortable” and “safe” are not always the same thing.
