At What Age Can Tight Shoes Cause A Bunion Deformity?

A recently published study underscores the critical role that footwear plays in the development of hallux abductovalgus  (HAV) deformity. González-Elena and coworkers studied 187 school children in southern Spain, with an average age of 8.07 years. The researchers measured foot length as well as the hallux valgus angle (HVA) of each child using a weight-bearing podogram image.¹ Telescopic gauges with protractors measured the inside length of the shoe worn by each subject. They considered the footwear poorly fitting or too short when the difference between the foot length (FL)  and the inside length of the shoe was less than nine mm.^2,3 In this study, 38.5 percent of the schoolchildren wore shoes which were too short.¹ A strong correlation existed between short footwear and hallux valgus angle in 10-year-old boys (r = 0.817; p = 0.025)  and in nine-year-old girls (r = 0.705; p = 0.005). This age range also had the highest incidence of poor shoe fit for both boys and girls. The authors note from their own previous research that peak longitudinal foot growth precedes the peak of overall body growth at the onset of puberty, and actually occurs in the age range of seven-to-eight years in girls and eight-to-nine years in boys.⁴ They recommend frequent shoe fit monitoring in all children between ages seven and 11 years.

Other studies show a strong correlation with improperly fitted footwear and increased HVA in pre-pubescent children of both sexes.^3,5-6 A recent study of 100 Polish schoolgirls showed that 40 percent of the children wore shoes too short in length.7 That study also showed an increased hallux valgus angle of 5.5 degrees which peaked at age nine,⁷ which was similar to the findings of González-Elena and colleagues.¹

A study published by Klein and coworkers evaluated 858 preschool children in Austria, age three-to-six years, and found that 70 percent wore shoes which were too short.³ The study also showed a direct correlation between short shoes and an increased hallux valgus angle. In other words, the shorter the shoe, the higher the value of the hallux valgus angle. In fact, the study showed that the risk of hallux valgus increases by 17 percent when wearing shoes too small by one size, by 37 percent if the shoes are two sizes too small, and 61 percent in the case of shoes too small by three sizes. A shoe size is equivalent to nine mm.⁸ Hence, the authors recommended that the optimal fit for children’s shoes should be greater than one size, or at least 10-to-12 mm longer than the foot of the child.

Is Shoe Fit Associated With Hallux Valgus In Older Patients?

With all the current excitement about new surgical approaches for treatment of hallux abductovalgus (HAV) deformity, I find there is little attention paid to preventive measures.  At the same time, one must recognize that reports consistently cite improperly fitted footwear as a significant extrinsic risk factor for developing HAV deformity.⁹ Multiple studies show an increased incidence and severity of HAV in patients who wear shoes with elevated heels and/or constrictive toe boxes.^10-13 The role of footwear causing bunions is underscored by studies showing that risk of HAV increases when women who are barefoot during early life change to a shoe-wearing lifestyle.^14-16

Constrictive footwear seems to cause more problems for adult women at a younger age. In a survey of over 2,000 women, Menz and coworkers found a graded increase in the risk of hallux valgus with increasing narrowness of the toe box in footwear worn between 20 and 29 years of age, and to a lesser extent, at ages 30 and 39 years.¹⁷ Now, we are learning that improperly fitted footwear will begin causing HAV deformity much earlier in life in both boys and girls.^1-6

Summary And Recommendations

Several studies verified that between 40 and 70 percent of children under the age of 12 in economically developed countries wear improperly fitted shoes.^1,3,7 The chance of finding improperly fitted shoes increases in age groups where foot growth is most accelerated, which is seven-to-eight years in girls and eight-to-nine years in boys.¹ At that age, an increased hallux valgus angle directly correlates with short or constrictive shoes.^1,7

In adult patients, fashion and lifestyle most likely drive the choice of constrictive footwear. However, children do not commonly wear high heels and so-called “fashionable shoes.” At the same time, in my observation, most children’s shoes have some taper or narrowing in the distal portion of the toe box. Therefore, in children, the condition of constrictive footwear is the result of wearing shoes too short for the user’s foot. The question is: Why are the majority of children living in modern industrialized countries wearing improperly fitted shoes? Failure to regularly monitor fit and appropriately replace shoes would be a likely explanation.

Clinicians evaluating young patients should always check shoe fit and educate parents about the risks posed by constrictive footwear. Parents should also learn how to evaluate shoe fit.  In next month’s blog, I will give tips for checking shoe fit and will expose several myths about simply relying on the “rule–of –thumb.”

Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. Dr. Richie is the author of a new book titled "Pathomechanics of Common Foot Disorders," which is available from Springer at https://www.springer.com/us/book/9783030542009 . He discloses that he is Founder and President of Richie Technologies.

References

1. González-Elena ML, Castro-Méndez A, Coheña-Jiménez M, Córdoba-Fernández A. Relationship of the use of short footwear with the development of hallux valgus in a sample of andalusian schoolchildren. Int J Environ Res Public Health. 2021;18(21):11244. doi: 10.3390/ijerph182111244.

2. Barisch-Fritz B, Schmeltzpfenning T, Plank C, Hein T, Grau, S. The effects of gender, age, and body mass on dynamic foot shape and foot deformation in children and adolescents. Footwear Sci. 2014;6:27–39.

3. Klein C, Groll-Knapp E, Kundi M, Kinz W. Increased hallux angle in children and its association with insufficient length of footwear: A community based cross-sectional study. BMC Musculoskelet. Disord. 2009;17:159.

4. González-Elena ML, Fernández-Espejo E, Castro-Méndez A, Guerra-Martín MD, Córdoba-Fernández A. A cross-sectional study of foot growth and its correlation with anthropometric parameters in a representative cohort of schoolchildren from southern Spain. Int. J. Environ. Res. Public Health. 2021;18:4031.

5. Kinz W, Groll-Knapp E, Kundi M. Hallux valgus in pre-school-aged children: The effects of too-short shoes on the hallux angle and the effects of going barefoot on podiatric health. Footwear Sci. 2021;13:29–42.

6. Martin-Casado L, Barquín C, Aldana-Caballero A, Marcos-Tejedor F, Aguado, X. Environmental factors as a cause of differences in the feet of Ecuadorian children and its relation to their footwear. Children. 2021;8:459.

7. Puszczalowska-Lizis E, Zarzyczna P, Mikulakova W, Migala M, Jandzis S. Influence of footwear fitting on feet morphology in 9 year old girls. BMC Pediatr. 2020;20:349

8. Cheng FT, Perng DB. A systematic approach for developing a foot size information system for shoe last design. Int J Ind Ergon. 1999;25:171-185.

9. Richie DH. Disorders of the First Ray, Part One: Hallux Abductovalgus. In: Pathomechanics of Common Foot Disorders. Springer, New York, 2020.

10. Nix SE, Vicenzino BT, Collins NJ, Smith MD. Characteristics of foot structure and footwear associated with hallux valgus: a systematic review. Osteoarthritis Cartilage. 2012;20:1059–1074.

11. Thompson FM, Coughlin MJ. The high price of high-fashion footwear. J Bone Joint Surg Am. 1994;76-A:1586–1593.

12. Frey C. Foot health and shoewear for women. Clin Orthop Relat Res. 2000;372:32–44.

13. Dawson J, Thorogood M, Marks SA, et al. The prevalence of foot problems in older women: a cause for concern. J Public Health. 2002;24:77–84.

14. Barnicot NA, Hardy RH. The position of the hallux in West Africans. J Anat. 1955;89:355-361.

15. MacLennan R. Prevalence of hallux valgus in neolithic New Guinea population. Lancet. 1966;1:1398-1400.

16. Kato T, Watanabe S. The etiology of hallux valgus in Japan. Clin Orthop Relat Res. 1981;157:78-81.

17. Menz HB, Roddy E, Marshall M, et al. Epidemiology of shoe wearing patterns over time in older women: associations with foot pain and hallux valgus. J Gerontol A Biol Sci Med Sci. 2016;71:1682–7.