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Wearing shoes of insufficient length during childhood has often been cited as leading to deformities of the foot, particularly to the development of hallux valgus disorders.

Until now, these assumptions have not been confirmed through scientific research. This study aims to investigate whether this association can be statistically proven, and if children who wear shoes of insufficient length actually do have a higher risk of a more pronounced lateral deviation of the hallux. The hallux angle and the length of the feet were recorded.

Personal data and different anthropometric measurements were taken. Exact examinations of the hallux angle could be conducted on a total of 1, individual feet. Only The others were characterized by lateral deviations valgus position at different degrees, equalling 10 degrees or greater in A significant relationship was observed between the lengthwise fit of the shoes and the hallux angle: the shorter the shoe, the higher the value of the hallux angle. There is a significant relationship between the hallux angle in children and footwear that is too short in length.

The fact that the majority of the children examined were wearing shoes of insufficient length makes the issue particularly significant. The etiology of hallux valgus deformities is complex. Besides intrinsic factors like heredity [ 1 — 6 ], pes planus [ 6 , 7 ], metatarsus primus varus [ 1 , 2 , 8 ], first metatarsal length [ 9 — 13 ] and a hypermobility of the metatarsocuneiform joint [ 1 ], extrinsic factors are also involved. Footwear - respectively the fit of shoes - seems to be a major extrinsic factor, since hallux valgus occurs preferential in shoe-wearing populations [ 5 , 14 — 16 ].

The fit of shoes is defined by numerous parameters such as length, width ball and heel , girth, and height of toe box and shape. However, length seems to be one of the most important parameters [ 17 ]. It has been indicated that this could lead to a deviation of the great toe [ 8 , 14 , 18 , 21 — 31 ]. Hallux valgus deformities are attributed to poorly-fitting footwear [ 14 , 21 , 25 , 27 , 29 , 32 , 33 ].

In addition, splay-foot and other deformities of the toes have been reported [ 19 ].

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  • Eckstein and Schmidt report contractures in the forefoot area, visible in podogram images of the metatarsal capitulum, possibly a sign of forefoot damage [ 21 , 29 ]. Muscular damage and deformity of the forefoot attributed to the constant exposure of small forces, such as those exerted by shoes of insufficient length, were also observed [ 24 ].

    None of the studies to date, however, has investigated whether there is a significant relationship between the wearing of shoes of insufficient length and a lateral deviation of the great toe. Further, for the first time, the study intends to differentiate between outdoor shoes and footwear worn inside the home or at child care facilities indoor shoes , because children in Austria spend more time per day wearing indoor than outdoor shoes.

    Pre-school children participated in the study. Overall, pre-school children, boys and girls aged 3 to 6. The sample size was based on the following considerations: At least 50 children should be included in each of the 16 subgroups, defined by gender 2 , rural vs.

    Children were tested in pre-schools. The drop-out rate was below 0.

    A carefully history and a static and dynamic clinical examination were conducted on the barefoot children. Data of children with clubfoot deformity, pes adductus, visible bunion deformities and surgical treatment of these deformities were excluded from statistical analysis drop-out rate 1.

    At the time the study was initiated and conducted from to , it was not mandatory under Austrian law for studies of this type to apply for approval from the ethics committee. However, all provisions of the Helsinki declaration concerning studies with human subjects were followed. Foot length was defined as the distance between the back of the heel and the tip of the longest toe.

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    Measurements were precise to 0. For ethical reasons, an assessment of the hallux angle based on x-ray measurements was not performed in this healthy population of children. Measuring the angle of the hallux.

    Due to the wide variation of cut-offs between normal and pathological angles found in the literature [ 19 , 31 , 33 — 37 ], we decided to assess the hallux angles with a precision of 1 degree using the method described above without a predefined cut-off point. To our knowledge, no evidence-based normal values and ranges of the hallux angle are available for children of such a young age, either based on radiographic measurements or based on data assessed by the above described external method.

    Categories introduced in this study are based on classes of hallux angles in degrees without any reference to "normal" values. The height and the weight of the children were measured and the BMI calculated according to the specific guidelines for young children [ 38 , 39 ]. Typical Austrian pre-school indoor shoe. Measuring device for the inside length of shoes.

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    A properly-fitting shoe should be at least 10 mm and optimally 12 mm longer than the foot. Comparisons between boys and girls and left vs. Categories for fit and categories for hallux angles were compared by Chi-square tests.

    Because left and right hallux angle had a highly significant correlation Pearson correlation coefficient , and the hallux angle for left feet was more pronounced, only data for left feet were selected for analyses for fit criteria.

    To test the functional association between hallux angle and the fit of shoes, a logistic regression analysis was performed with "fit" for street and indoor shoes as forced inclusion variables, and gender, age, body weight and body mass index as stepwise inclusion variables. Number of children in the 5 categories of hallux valgus angles.

    However, the left hallux angles were on average 0. An analysis of gender effect in these categories of fit showed that boys were more likely to wear poorly-fitting shoes than girls. A stepwise logistic regression analysis revealed a significant effect of the criterion lengthwise fit of indoor shoes on the risk of a more pronounced lateral deviation of the great toe.

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    Effects of the criterion lengthwise fit of outdoor shoes showed a similar tendency, but were not significant. Of all variables included stepwise in the analyses, only the variable gender proved significant.

    Age, body weight, and body mass index had no significant effect.

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  • Male gender was associated with an odds ratio of 1. In order to assess the relationship between poorly-fitting shoes and risk of hallux valgus, we choose a representative cross-sectional study design. Although it has been speculated upon frequently in the literature [ 8 , 14 , 18 , 21 — 31 ], this investigation provides the first systematic empirical data supporting the assumption that shoes of insufficient length are a risk for healthy foot development.

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  • This study was also the first to examine children of this young age before school entry 3 - 6. Furthermore, data published to date provide no information about indoor shoes.

    According to our results, only few children wear indoor shoes that fit well, and the fit of indoor shoes is generally poorer than that of outdoor shoes.

    This may partly be due to the fact that parents pay less attention to indoor shoes than to outdoor shoes. Pre-school teachers reported that in many cases, the indoor shoes were not replaced for a whole school year.

    The risk of a greater hallux angle for children wearing poorly-fitting indoor shoes is markedly higher than for children wearing poorly-fitting outdoor shoes.

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    The increased risk might be due to the worse fit of the indoor shoes, and to the fact that children of this age group spend more time per day wearing indoor than outdoor shoes. There are, however, some limitations to our study. Intrinsic risk factors for an increase in the hallux angle were only partly controlled in our study as no x-ray images were available for this healthy childhood population.

    No information about hallux valgus family history was available. However, it seems unlikely that children with a family history of hallux valgus would wear shoes of insufficient length more frequently than others, increasing the association between too-short shoes and increased hallux angle found in our study.

    Hallux angle assessment is performed by radiographic measurements in most studies. In our study, for ethical reasons, an external measurement method based on footprints was used.

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    They conclude that despite the high correlation, caution is required in inferences made from data obtained by one method to data obtained by the other. Since we assessed shoes at the same time as foot measurements were conducted, we were not able to investigate the relationship between the duration of wearing poorly-fitting shoes and the development of pathologies.

    This results in exposure misclassification, reducing the risk estimates, because children with appropriate shoes might have purchased them recently and worn them for just a short period of time.

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    But it is unlikely that non-fitting shoes were worn only on the particular day when measurements were done. Another important aspect that should be addressed in future investigations is whether, after changing footwear habits, hallux valgus is reversible and how long it takes for the changes to develop. Eckstein [ 21 ] and Craigmile [ 13 ] provide initial, encouraging findings on this question in studies in which a reversal was observed in some children after periods of wearing properly-fitting shoes.

    In the meantime, a new research project in cooperation with the Austrian Ministry of Health has been started. It is dedicated to finding out what has to be done to ensure that children have correctly fitting shoes, and to prove the effects of intervention programmes. It could be proven that the risk of having a hallux angle deviation is increased in children wearing shoes of insufficient length.

    The fact that From a public health perspective, these findings are especially important in light of the large number of children wearing poorly-fitting shoes. Therefore, it is necessary to provide parents and the general public with comprehensive information on the importance of properly-fitting shoes and the criteria of a proper fit. We gratefully acknowledge the assistance of Univ. The study received financial support from the Austrian Ministry of Health.

    This article is published under license to BioMed Central Ltd. View archived comments 1. Increased hallux angle in children and its association with insufficient length of footwear: A community based cross-sectional study. BMC Musculoskeletal Disorders 10 Abstract Background Wearing shoes of insufficient length during childhood has often been cited as leading to deformities of the foot, particularly to the development of hallux valgus disorders.

    Methods pre-school children were included in the study.

    Results Exact examinations of the hallux angle could be conducted on a total of 1, individual feet. Conclusions There is a significant relationship between the hallux angle in children and footwear that is too short in length. Study group, study site Overall, pre-school children, boys and girls aged 3 to 6. A straight line 1 was drawn through the most medial points of the first metatarso-phalangeal joint and the heel inside edge.


    A second straight line 2 was drawn through the first metatarso-phalangeal joint and the great toe proximal phalanx. According to the medial or lateral deviation of the great toe in relation to the inside edge, the angle between these two straight lines 3 was then recorded as the hallux angle in a valgus or varus position Figure 1. Measurements were assessed in 1-degree steps.

    All reported measurements were, however, conducted by only one person. Figure 1 Measuring the angle of the hallux.