A 14-year-old female came to clinic with a history of rolling her right ankle over on a player’s foot the evening before at a basketball game. She didn’t feel or hear a “popping” sensation and was able to walk afterwards. She iced the ankle during the evening and in the morning. She complained of pain around the lateral malleolus and also around the 5th metatarsal head of her right foot. She was concerned because state playoff games were to begin in about 10 days. She denied any other foot or extremity pain. The past medical history was positive for a soft tissue wrist injury 1 year previously that healed without problems.
The pertinent physical exam showed a healthy female with normal vital signs and growth parameters. Her right ankle was mildly swollen without bruising. She was tender anterior to the lateral malleolus and at the 5th metatarsal head. She had no pain in the rest of the foot and ankle. She did have mild great toe pronation with first metatarsal head prominence. This was noted bilaterally.
The radiologic evaluation of foot and ankle radiographs were negative.
The diagnosis of of mild ankle sprain with incidental mild hallux valgus was made. The pediatrician counseled her about supportive care for the ankle with instruction on returning to play. When questioned about the hallux the patient denied any pain, problems with walking, shoe wear or fitting shoes. She said usually wore flatter, open shoes or athletic shoes. The pediatrician noted that hallux can become worse with time, but the family declined seeing a podiatrist or orthotist at that time, and said they would consider it after the state playoff games.
Hallux valgus (HV) is commonly called a bunion. The word bunion comes from Greek meaning “turnip.” The great toe is seen to be pronated with a prominent first metatarsal head which can be swollen and painful, which can look like a turnip. They are also called metatarsus primus varus, or metatarsus primus adductus. Angulation can occur in other joints such as at the 5th metatarsal head and is sometimes called “bunionette” or tailor’s bunion. The cause “…for the pathological deformity is considered to be metatarsus primus varus… but there often are other anatomic abnormalities present.” These include distal metatarsal articular angulation, oblique metatarsal-cuneiform articulation, flexible pes planus, long first ray, ligamentous laxity, and metatarsus adductus. Shoe wear and pressure may not be the cause of the deformity but may be the cause of the symptoms such as pain with high heel wearing. Increased or decreased muscle tone may be the cause of the deformity in patients with neurological conditions. HV in children is relatively uncommon, but more common in the adolescent population. However “[i]t is estimated that 40% to 50% of adult bunions actually have their onset in childhood.” Females are more common (up to 80%).
On physical examination it is important to assess if the HV is rigid or flexible. As with many pediatric orthopaedic conditions, rigid deformities are causes for concern. Other abnormalities such as pes planus and metatarsus adductus should be noted. Radiographs of the feet in weight-bearing and non-weight-bearing views help determine the bony pathology, whether or not the growth plates are open or closed, and to evaluate the angles particularly the HV angle. Mild HV deformities are >10 degree angulation, moderate is 25-40 degree angulation and severe is > 40 degree angulation.
Congenital HV is rare and usually treated conservatively with padding and physical therapy.
Juvenile HV occurs in the skeletally immature patient. Usually it is progressive because of the flexibility of the tissues in the foot. Initial treatment is conservative with padding, bracing (e.g. orthotics, splinting, bracing) and physical therapy, but often this still progresses. Orthotists can also counsel on shoe selection. Main indication for surgery is pain and interference with walking or shoe wearing. Angle progression and severity also assist in determining surgical timing. There are numerous (> 100 different) operative treatments but no specific consensus on the optimal treatment. Operating on the skeletally immature foot has increased risk of affecting the growth plates, recurrence and need for surgical revision but the advantage of operating earlier is the process is less advanced. Operating on the skeletally mature foot has the advantages of not affecting the growth plate but the disadvantages of operating when the disease is likely more advanced. Outcomes are age dependent and there is an increased recurrence risk in skeletally immature patients. Recurrence overall is still relatively common. Factors associated with increased risk include hypermobility, hyperlaxity, rheumatoid arthritis, hypothyroidism, neuromuscular condition (e.g. Down Syndrome, Charcot-Marie-tooth, muscular dystrophies, etc.) or cerebrovascular accident, non-compliance with surgical instructions, and continued use of inappropriate footwear such as high heels.
Questions for Further Discussion
1. What are indications for referral to orthopaedics, sports medicine or podiatry?
2. What is club foot and how is it treated? A brief review can be found here
3. What are the Ottawa Ankle Rules? A review can be found here
- Specialty: Orthopaedic Surgery and Sports Medicine |
Radiology / Nuclear Medicine / Radiation Oncology
- Age: Teenager
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Raikin SM, Miller AG, Daniel J. Recurrence of Hallux Valgus. Foot and Ankle Clinics. 2014;19(2):259-274. doi:10.1016/j.fcl.2014.02.008
Chell J, Dhar S. Pediatric Hallux Valgus. Foot and Ankle Clinics. 2014;19(2):235-243. doi:10.1016/j.fcl.2014.02.007
Rampal V, Giuliano F. Forefoot malformations, deformities and other congenital defects in children. Orthopaedics & Traumatology: Surgery & Research. 2020;106(1):S115-S123. doi:10.1016/j.otsr.2019.03.021
Bunions – OrthoInfo – AAOS. Accessed October 28, 2021. https://www.orthoinfo.org/en/diseases–conditions/bunions/
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa