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figure 8.6   Excessive pronation associated with leg length difference resulting in increased 
pressure on the medial side of the foot
Pressure from tight footwear in patients with neuropathy is a common
problem as they tend to chose shoes that are too tight. The reason for
this is that they are trying to achieve the sensation of feeling the shoes
on the feet and increased proprioception. This leads to continuous pres-
sure at the margins and toes, preventing normal toe function and increas-
ing pressure on the metatarsal heads. Additional forces across the
metatarsal heads are a result of the development of the high medial
longitudinal arch together with displacement or atrophy of the plantar
metatarsal fat pad, which result in an inability to absorb the increasing
forces. Stiffening of local soft tissues through glycosylation also adds to
the loss of resilience. There may be also areas of localized high pressure
as a result of limited joint mobility, also through glycosylation, and the
shoes may become tight because of oedema. This is particularly a
problem in the neuroischaemic foot because patients with peripheral
vascular disease often have renal and cardiac problems which lead to
peripheral oedema. There may also be problems with swelling when the
foot is ulcerated and/or infected, or if the patient develops acute Charcot
neuroarthropathy.
There are studies to support the belief that inappropriate footwear,
purchased by patients in retail outlets, can cause ulceration. Apelqvist
et al (1990) identified footwear as the precipitating cause in the majority
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