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Juvenille HAV with possible neurological causes

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Teash13, Jun 1, 2009.

  1. Teash13

    Teash13 Member

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    I have a 9 year old girl with quite impressive HAV. Her mother says it has been getting worse. Child sometimes gets sore feet when she wears crappy shoes.

    She pronates excessively through her STJ. She has internal rotation of the knee
    No muscle tightness noted

    Callus SM 2 and 3 BF and medial 1st BF

    Some clawing of the lesser toes

    RCSP 3 degress everted
    NCSP 0 degrees

    Tried anti pronation strapping and this improved her calc eversion and pornation.

    Have referred for xrays. Looking at getting orthoses made.

    No abnormalities noted for monfilament or vibration testing. The thing that I'm worried about is I couldn't get a reflex from the L leg, which is the foot with the bigger HAV.

    Is is worth referring her for surgery? Are there any further neurological tests I can do to find out more?

    And am I missing something?

    Please any info would be great
  2. Hallux valgus is a progressive deformity. What are her HA angles?

    So do I.

    Which reflex, there are many to choose from.

    British Journal of Podiatry November 2004 ; 7 (4): 101-105
    Conservative treatment of juvenile hallux
    valgus - A seven-year prospective study
    Andrew J H Macfarlane, T E Kilmartin

    This study has demonstrated that night splints can, over an average of 3
    years treatment, prevent the deterioration of juvenile hallux valgus and
    subsequent development of associated deformities of the other digits. There
    is clear justification for deferral of surgical reconstruction until
    skeletal maturity when the outcomes of surgery are likely to be more
    predictable. Further, night splint therapy should be considered as a first
    line treatment for hallux valgus.
  3. Adrian Misseri

    Adrian Misseri Active Member

    9 years old with HAV. I'd be getting a surgical opinion, especially if it's painful. She's got a long time on that foot.....
  4. efuller

    efuller MVP

    Anyone done any studies on the reocurrence rate after bunion surgery. I'd suspect it would be higher in the more active age groups.


  5. If memory serves the Cochrane review reported something like a 30% dissatisfaction rate post surgery. If she were my nine year old, she wouldn't be going anywhere near surgery yet.
    Abstract here:
    Last edited: Jun 2, 2009
  6. Sydpod63

    Sydpod63 Welcome New Poster

    Are there any signs of underlying rheumatological problems? Any other joint pain etc possibly pointing to a juvenile rheumatoid arthritis? Can you find an underlying cause for the HAV?

    I would be ruling out any systemic problems and then trying conservative treatment (such as splinting) prior to running down the surgical path.
  7. Teash13

    Teash13 Member

    I have finally got some xrays.
    valgus angle is 37 degree on left and 22 degree on right.
    I am going to try some night splints and orthotic prescription as well as a referral to surgeon for input.

    The reflex I couldn't get was the left pateller tendon reflex. Right one was easy to get.
  8. drsarbes

    drsarbes Well-Known Member


    When confronted with a juvenile HAV (under 12) it is a case by case decision.

    If I feel I can correct the deformity with a distal osteotomy (as you know, the epiphysis on the first metatarsal is proximal) then I normally do not wait. It do not feel the arguments to wait outweigh the probability of the IM angle increasing and the joint adapting (both undesirable). In addition, I feel the correction of the IM angle makes it much easier to control the rest of the foot with an orthotic (my opinion here)

    In your case, the 22 IM angle is substantial and may require more than a distal osteotomy to correct, in which case you may be obligated to wait until the plates close.

    Good luck.

  9. Steve, good post :good: I concur with your thoughts here given that these are significant HA angles and the differentiation in terms of location of surgical procedure. One point though, I don't think the 22 degrees referred to the IM angle.
  10. Every case of juvenile hallux abducto valgus (HAV) deformity I have ever seen also has a high degree of metatarsus adductus and a distal 1st metatarsal head that has a relative small radius of curvature on the AP radiographic projection. I believe that these two structural characteristics are necessary to create HAV deformity in the pre-adolescent child, but the presence of these two structural characteristics do not necessarily mean that juvenile HAV will occur.

    Like any joint deformity, it all has to do with internal and external moments (i.e. rotational forces) acting across a joint. In the case of juvenile HAV, it all has to do with internal and external hallux abduction moments at the 1st metatarso-phalangeal joint during weightbearing activities.
  11. Mark_M

    Mark_M Active Member

    I would definatley get a surgical opinion.
    Your patient seems to be largley asymptomatic so im not sure what you could expect to achieve with orthotics and strapping.

    I had a recent case witha 14 year old boy. The surgeons opinion was to wait 12 months due to the epiphyseal plate, new xrays and then another review. (thats still 6 months away)

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