Juvenile hallux valgus (bunion)
Juvenile hallux valgus is a foot deformity in which the big toe drifts towards the other toes and a prominence appears at its base, known as a bunion. It may cause no discomfort or it may be painful when walking, playing sport or wearing certain shoes. When pain persists and limits daily activity, there are surgical options to correct the deformity, including minimally invasive percutaneous techniques.
- Typical age
- Childhood and adolescence, especially during growth
- Also known as
- Juvenile bunion · Adolescent bunion · Adolescent hallux valgus · Bunion
What is it?
Juvenile hallux valgus is a forefoot deformity that appears during childhood or adolescence. The big toe drifts towards the other toes and the first metatarsal, the bone that connects the toe to the midfoot, takes up a position that makes its base more prominent. This prominence is what we call a bunion. It can affect one or both feet, although it often appears in both.
There is no single cause. Family predisposition and the shape of the foot bones play an important role. Ligament laxity and certain features of the way the foot strikes the ground can also contribute. Narrow shoes can increase pressure and discomfort over the prominence, but they are not the only cause of the deformity.
The problem usually becomes more noticeable during growth. Some adolescents have hardly any symptoms, while others have pain, redness from shoe rubbing or difficulty with certain sports. The course varies: not all bunions progress and not all need surgery.
Unlike adult hallux valgus, an adolescent may still have bone growth to complete. That is why, before considering an operation, it is important to assess skeletal maturity, the severity of the symptoms and the impact on daily life.
Signs parents may notice
The most common signs are:
- Big toe drifting: it appears to lean towards the second toe instead of staying straight.
- Bump at the base of the toe: a prominence appears on the inner edge of the foot.
- Redness or rubbing: the skin can become irritated where it touches the shoe.
- Pain when walking or playing sport: discomfort may increase when running, jumping or standing for many hours.
- Difficulty finding comfortable shoes: some shoes press on the bunion and cause pain.
- Changes in the position of the other toes: in more marked deformities, the big toe may move closer to or push against the second toe.
A bump does not necessarily mean there is a significant problem. It is mainly worth watching for pain, progression of the deformity and any limitations it causes.
When to see a specialist
An assessment by a paediatrician or an orthopaedic surgeon specialising in the foot and ankle is advisable if:
- The adolescent has recurring pain at the base of the big toe.
- The drift seems to increase during growth.
- The discomfort makes it hard to walk, play sport or wear ordinary shoes.
- There is frequent rubbing, calluses or problems with the neighbouring toes.
- The pain persists despite comfortable shoes and changing the activities that trigger it.
When is it urgent?
Hallux valgus usually develops slowly and is not an emergency in itself. However, an urgent medical assessment is advisable if there is sudden severe pain, marked swelling, obvious redness and warmth, fever, inability to put weight on the foot, or if the deformity appears after an injury. These symptoms may indicate another problem that needs evaluation.
How is it diagnosed?
The diagnosis is made through the clinical history and physical examination. The specialist will ask when the discomfort started, whether there is a family history, which activities cause pain and how the deformity has changed.
The examination assesses the alignment of the big toe, the bony prominence, joint movement, foot flexibility and any pain or problems with the neighbouring toes. The way the foot strikes the ground, footwear and the mobility of other joints are also examined when necessary.
If the deformity needs to be studied more precisely, weight-bearing X-rays of both feet (taken standing up) may be requested. These images allow the angles between the bones to be measured, joint alignment to be assessed and treatment to be planned if surgery is being considered.
Not every adolescent needs imaging. It depends on the symptoms, the examination and whether surgical treatment is a possibility.
Treatment
Treatment depends on how severe the pain is, the functional impact, how the deformity is progressing and how much growth remains. In most cases treatment starts with conservative measures.
Conservative treatment
The aim is to relieve discomfort and make everyday activities easier. The main measures are:
- Suitable footwear: shoes with enough width at the front that do not squeeze the toes or rub the bunion.
- Adjusting activity: temporarily reducing activities that trigger pain and resuming them gradually as tolerated.
- Insoles: can help when there is an associated foot-strike problem or a specific indication, although they do not correct the bone deformity on their own.
- Toe spacers or splints: in some cases they relieve rubbing or improve comfort, but they do not guarantee that the bunion will stop progressing.
- Physiotherapy and exercises: can help improve mobility, function and foot control in selected patients.
These measures do not usually correct bone alignment permanently, but they can control symptoms and keep discomfort from interfering with daily life. Surgery is not indicated just because there is a visible prominence.
Surgical treatment
In children and adolescents, the choice of surgery depends especially on how much growth remains, how severe the pain is and the characteristics of the deformity. There is no single technique that suits every patient. In some children growth can be used to gradually improve alignment; in selected adolescents, the position of the bones may need to be corrected directly.
Lateral hemiepiphysiodesis of the proximal physis of the first metatarsal
In children with juvenile hallux valgus who still have bone growth ahead of them, there is a surgical technique that uses growth to gradually improve the alignment of the big toe: lateral hemiepiphysiodesis of the first metatarsal.
The technique partially slows growth on the outer side of the growth plate (physis) at the base of the first metatarsal. Because the two sides of the bone then grow differently, the aim is to gradually change its orientation and reduce the angle between the first and second metatarsals.
Which patients is it suitable for? It may be considered in children with a symptomatic or progressive deformity who still have enough growth remaining. Chronological age alone does not determine the indication: bone maturity and remaining growth need to be assessed through examination and appropriate imaging.
What results can be expected? Correction happens gradually as the child grows. Published studies describe improvements in pain and function, along with a generally moderate reduction in the radiographic angles of the deformity. Its aim may therefore be to improve alignment and, above all, to limit progression of the bunion, without guaranteeing complete correction.
Because the technique depends on growth, it becomes less effective when little growth remains. A further operation may be needed if correction is insufficient, a complication occurs or the deformity persists.
Clinical and X-ray follow-up is essential to monitor progress, check the response to treatment and detect any problems related to the implant or to growth.
Hemiepiphysiodesis is a specific option for selected patients and does not replace direct bone correction techniques in every case. The decision must be individualised according to the symptoms, the anatomy of the foot and skeletal maturity.
Reference: Artioli E. et al. First Metatarsal Hemiepiphysiodesis for the Treatment of Juvenile Hallux Valgus: A Systematic Review. Journal of Pediatric Orthopaedics, 2023. View on PubMed.
Percutaneous surgery in adolescents: PECA and other minimally invasive techniques
When pain persists despite conservative treatment and the deformity limits daily life, surgical correction may be considered. In adolescents, the decision must be individualised, taking into account bone maturity, the severity of the deformity and the risk of recurrence.
Percutaneous techniques correct the position of the bones through small incisions, guided by X-ray imaging during the operation. The aim is to improve the alignment of the big toe, reduce the painful prominence and make it easier to wear shoes and be physically active.
The PECA technique (Percutaneous Chevron Akin) combines two procedures:
- Chevron osteotomy of the first metatarsal: changes the position of the metatarsal head to correct part of the drift.
- Akin osteotomy: corrects additional drift of the proximal phalanx of the big toe when indicated.
Internal fixation holds the correction while the bone heals. The minimally invasive approach usually leaves small scars, although recovery and the risk of complications depend on the technique, the fixation and each patient’s characteristics.
Centrolock is a percutaneous correction system that combines an osteotomy of the first metatarsal with a specific fixation implant. It is designed to help correct the position of the metatarsal in different planes and keep the osteotomy stable. Whether this system is chosen depends on the anatomy, the type of deformity and the experience of the surgical team.
Although these techniques can give good results in correcting hallux valgus, the specific evidence in adolescents who are still growing is more limited than in adults. They should therefore not be chosen simply because they are minimally invasive: careful patient selection and assessment of the maturity of the growth plates are essential.
Outlook and recovery
Recovery depends on the technique used, the stability of the fixation and each child’s progress.
- After hemiepiphysiodesis: regular clinical and X-ray check-ups are needed to assess the gradual correction and detect any complications related to the implant or to growth.
- After percutaneous surgery: early weight-bearing in a post-operative shoe may be allowed for some procedures, although instructions vary depending on the osteotomy and its fixation.
- School: a return is usually possible before a return to sport, as long as the pain is under control and getting around is safe.
- Return to sport: must wait until the bone has healed adequately and function has recovered sufficiently. The exact timing will be decided by the specialist at check-ups.
Increasing pain, marked redness, discharge from the wound, fever or new difficulty putting weight on the foot require medical assessment.
Which technique is most suitable?
The decision does not depend only on chronological age, but also on remaining growth and the specific shape of the deformity. Hemiepiphysiodesis aims to guide growth and can be useful in selected patients; percutaneous techniques aim to correct the bone deformity directly when surgery is indicated.
An assessment by a foot and ankle specialist makes it possible to review the X-rays, determine skeletal maturity and explain the benefits, limitations and risks of each option to the family.
This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.