Kevin Rosenbloom provided the illustration.

A study released recently emphasizes the importance of footwear in the development of hallux abductovalgus (HAV) deformity. González-Elena and colleagues looked at 187 schoolchildren in southern Spain, who were on average 8.07 years old. Using a weight-bearing podogram image, the researchers measured each child’s foot length and hallux valgus angle (HVA). 1 The inside length of each subject’s shoe was measured using telescopic gauges and protractors. When the discrepancy between the foot length (FL) and the inner length of the shoe was less than nine mm, they deemed the footwear to be ill-fitting or too short. 2,3 38.5 percent of the pupils in this survey wore shoes that were too short. 1 In 10-year-old males (r = 0.817; p = 0.025) and nine-year-old girls (r = 0.705; p = 0.005), there was a high association between short footwear and hallux valgus angle. For both boys and girls, this age group had the highest incidence of poor shoe fit. The authors point out that peak longitudinal foot growth occurs in the age range of seven to eight years in girls and eight to nine years in boys, and that it happens before the peak of overall body growth at the onset of puberty. 4 All youngsters between the ages of seven and eleven should have their shoe fit checked on a regular basis, according to the researchers.

 

In pre-pubescent children of both sexes, other studies reveal a strong link between incorrectly fitted footwear and increased HVA.

 

3,5-6 According to a recent study of 100 Polish schoolgirls, 40% of them wore shoes that were too short in length. 7 In that study, the hallux valgus angle grew by 5.5 degrees and peaked at age nine,7 which was identical to González-Elena and colleagues’ findings. 1

 

Klein and associates assessed 858 preschool children in Austria, ranging in age from three to six years, and discovered that 70% of them wore shoes that were excessively short.

 

3 The study also discovered a link between wearing short shoes and having a higher hallux valgus angle. In other words, the greater the hallux valgus angle, the shorter the shoe. According to the study, wearing shoes that are one size too small raises the risk of hallux valgus by 17 percent, two sizes too small increases the risk by 37 percent, and three sizes too small increases the risk by 61 percent. A shoe size equals nine millimeters. 8 As a result, the authors suggested that the best fit for children’s shoes is bigger than one size, or at least 10-to-12 mm longer than the child’s foot.

 

Is there a link between shoe fit and hallux valgus in older patients?

With all of the recent enthusiasm about new surgical techniques for treating hallux abductovalgus (HAV) deformity, I’m finding that preventive strategies are getting a lot of attention. At the same time, it’s important to note that incorrectly fitting footwear is consistently cited as a substantial extrinsic risk factor for HAV deformity. 9 Patients who wear shoes with elevated heels and/or constrictive toe boxes had a higher frequency and severity of HAV, according to multiple studies. 10-13 Studies suggest that when women who were barefoot throughout their childhood switch to a shoe-wearing lifestyle, their risk of HAV increases. 14-16

 

Adult women appear to have more difficulty with constrictive footwear when they are younger. Menz and coworkers discovered a graded increase in the likelihood of hallux valgus with increasing narrowness of the toe box in footwear worn between the ages of 20 and 29, and to a lesser extent between the ages of 30 and 39, in a sample of over 2,000 women. 17 Now we know that incorrectly fitting footwear can cause HAV malformation in both boys and girls much earlier in development. 1-6

 

Conclusions and Recommendations

According to several surveys, between 40 and 70 percent of children under the age of 12 in economically developed countries wear shoes that are not correctly fitting.

1,3,7 In the age periods where foot growth is most rapid, which is seven to eight years for girls and eight to nine years for males, the likelihood of discovering improperly fitted shoes increases. 1 Short or constrictive shoes are directly related to an increased hallux valgus angle at that age. 1,7

 

Constrictive footwear is most commonly chosen by adult patients because of their fashion and lifestyle. Children, on the other hand, rarely wear high heels or so-called “fashionable shoes.” At the same time, most children’s shoes, in my experience, feature a taper or narrowing in the distal area of the toe box. As a result, constrictive footwear in youngsters is caused by wearing shoes that are too short for the user’s foot. Why are the majority of youngsters in modern industrialized countries wearing shoes that are not correctly fitted? A common cause would be a failure to monitor fit and replace shoes on a regular basis.

 

When examining children, clinicians should always examine shoe fit and inform parents about the dangers of constrictive footwear. Parents should also learn how to assess the fit of their children’s shoes. In next month’s blog, I’ll discuss how to evaluate shoe fit and debunk some common misconceptions about using the “rule of thumb.”