You noticed it in the summer, with sandals: at the base of your daughter's big toe there is a bump that you did not see last year, and the toe points towards the others. Then you looked at your own feet. Then you thought of your mother. And in the evening you searched for "adolescent hallux valgus", finding two opposing worlds: those selling insoles and splints with promises to straighten it, and those who talk only about the operating theatre.
Here is the answer straight away. Juvenile hallux valgus is largely a family matter, and that is not a polite way of saying "nothing can be done". It is not straightened by gymnastics, by insoles or by night splints: none of these has been shown to stop the deviation, and the best study available even points in the opposite direction. But the reason a young person comes to us is not the crooked toe: it is pain in the shoe, the blister on the side of the foot, training that becomes a problem. On that, something can be done, and surgery, in growing years, is a decision to postpone, not to bring forward.
How common it is, and at what age it shows
The two key numbers come from different studies and together they tell a story of growth. A British screening of 6,000 children aged 9 to 10 found 122 with hallux valgus: about 2 in 100 already at primary school. A German cross-sectional study of 2,368 adolescents, average age 14.5, examined by school doctors, measured a prevalence of 3.5%; there, 14% reported foot pain, more frequent in those with a deformity (17.8% against 13.4%).
The German authors separate the deformities into two groups. Flexible flat foot (6.2%) and broad foot they call physiological variations with no association with pain; in the other group, the one that goes hand in hand with pain, they place rigid flat foot, cavus foot and hallux valgus. Not everything seen in a growing foot is the same: most of it is normal, and we covered this in Flat foot in children: when something really needs doing. Hallux valgus sits in the other column.
Family history: the fact nobody tells you
When you looked at your own feet and thought of your mother, you made the most accurate diagnosis of the whole evening.
A Spanish study built three-generation family trees for 350 patients with painful hallux valgus, selected from 1,174 consecutive cases: 90% had at least one affected relative, and in 244 of the 350 families three or more were affected, with up to 16 people in the same family. The authors estimate a penetrance of 56% and a picture consistent with autosomal dominant transmission with incomplete penetrance.
Two clarifications: those 350 were overwhelmingly adults (average age 47.8 years; juvenile hallux valgus was diagnosed in 15 of them) who came to a specialist centre for a painful big toe, so a sample selected towards the more marked cases; and it is a questionnaire on family history, not a genetic analysis.
The Framingham Foot Study estimated the heritability of hallux valgus in 1,370 adults with known family structure: between 0.29 and 0.89 depending on age and sex, that is, from a third to nearly nine tenths of the variability explained by genetics. Here too the caveat must be stated: those people were on average 66 years old, not fifteen.
For young people the figure comes from a series of 45 young patients operated on over eleven years by an American surgeon: 88% female, 40% of the deformities appearing at 10 years or earlier, maternal transmission in 72% of cases, and tight shoes cited by just 24%. It is a retrospective surgical series and describes who reaches the operating theatre, not the general population, but the ratio between those two numbers shows which way the balance tips.
It is not your mother's hallux valgus (and this changes everything)
It looks like the same thing seen thirty years earlier, and it is not: this is why in growing years surgery is approached with caution. In adults the big toe drifts sideways as the joint falls out of alignment; in a teenager something else often happens. In a study of 57 feet from patients aged 10 to 18, 98.2% had an altered distal articular angle of the first metatarsal, averaging 21.4 degrees, and in 89.4% the joint was congruent: the toe was deviated, but perfectly aligned within the deviation. The authors conclude that it is precisely the inclined joint surface that distinguishes juvenile hallux valgus from that of adults; the same observation was already present in the American surgical series, with an altered articular angle in 48% of cases and an average of 15.3 degrees in congruent joints against 7.9 in subluxed ones.
A second distinguishing feature comes from a large sample: comparing 160 patients with juvenile onset and 160 with adult onset (640 feet), the deviation within the big toe, between the two phalanges, was present in 63% of the juvenile-onset cases against 28% of the adult-onset ones.
Why does this matter to you? Because it changes the meaning of the word "straighten". If the toe is crooked but its joint is aligned, the deviation is not a toe out of place: it is the shape of the bone and of its joint surface, and no splint, spacer or exercise re-orients a joint surface. It is also the reason surgery is harder here: correcting the axis without touching the joint inclination leaves a foot that tends to return to how it was.
Does it get worse as they grow?
Yes, but with a detail that removes a good deal of anxiety. A Korean study followed 133 feet of children under 15 for at least a year each: the deviation angle increased on average by 0.8 degrees a year, but under the age of 10 the progression was 1.5 degrees a year, while in older children the increase did not reach statistical significance.
Put plainly: much of the worsening has already happened. If your son is fourteen you are not in a race against time, and that is the best argument against the solutions bought on impulse at night.
Insoles, spacers, night splints: what the evidence really says
Here we must be direct, because this is where money gets spent.
The only randomised study conducted precisely on children with hallux valgus comes from that British screening: the 122 children found positive were randomly assigned to an insole or to no treatment, and about three years later 93 were X-rayed again. The result, in full: the angle of the metatarsophalangeal joint had increased in both groups, but more in the treated group. And in children with the deformity on one side only, hallux valgus appeared in the healthy foot too despite the insole.
It must be read with the right measure: it dates from 1994, uses a single insole model, and the difference against the treated group does not prove that the insole does harm. It shows that it does not stop progression: exactly the thing it is sold for.
The Cochrane review of interventions for hallux valgus, covering 21 randomised studies of generally poor quality, says the same: in the three studies of 332 participants comparing a conservative treatment with no treatment, there was no evidence of a difference in outcomes, and insoles and night splints were not found to be more useful than not treating. It is dated, and the updated version is now withdrawn from the Cochrane library.
The more recent word is the systematic review with meta-analysis published in Arthritis Care & Research in 2022, covering 18 studies of non-surgical treatments. The five meta-analyses carried out (insoles, splints, manual therapy, taping added to exercises) showed no significant effects on the main outcomes, foot pain and deviation angle. Eight individual studies reported a significant reduction in pain and four a reduction in the angle, but most were on small samples and had risk-of-bias problems. Conclusion: low certainty, and a reduction in pain is more likely than an improvement in the angle.
The work pointing the other way should also be mentioned. An Argentinian study treated 56 children and adolescents with a thermoplastic night splint, periodically remodelled, plus exercises, with follow-up from two to six years: the metatarsophalangeal angle, the intermetatarsal angle or both had improved in about half of the feet. But there was no control group, and in a condition that progresses little on its own after the age of ten, "half improved" is not enough to credit the splint.
What exercise can do (and what it cannot)
The obvious objection is: so physiotherapy is useless?
It is useful, but for something else. Not for straightening the toe (that is the shape of the bone), but for reducing pain and making the foot more tolerant: the outcome that the 2022 review identifies as the most attainable, and the only one that really matters to your young person.
In practice we look at three things. Where it hurts: the bump rubbing against the shoe and the soreness under the head of the second metatarsal are different problems, and this is not theory, because in the study of 10-to-18-year-olds the deviation of the big toe correlated with greater pressure under the head of the second metatarsal, and the pressure-time integral at that point was associated with worse scores reported by the patients themselves (the pressure measurements, however, were available for only 15 of the 32 patients). How they push off: a big toe that does not take part in the push-off offloads work onto the neighbouring toes. What they need to do: the gymnastics suited to a foot that copes with four training sessions a week is not the same as one that copes with six hours of school shoes.
The repertoire, with honesty about what improves and what does not, we have already set out for adults in Hallux valgus: which exercises really improve anything: it applies to a young person too, with the stated goal from the start: less pain, not a straight toe.
Shoes: the only daily lever
Shoes did not cause your son's or daughter's hallux valgus: the family did. But shoes are the only thing you can change tomorrow morning.
A cross-sectional study measured the real internal length of shoes and the big toe angle in 187 school-age children: 38.5% wore shoes that were too short. Across the whole sample there were no significant differences in angle by age or sex, but in two subgroups the correlation between a short shoe and a larger angle was strong (r = 0.817 in 10-year-old boys; r = 0.705 in 9-year-old girls), and the authors insist on the practical point: the shoe should be adjusted to the speed at which the foot grows at puberty. The limitation matters: it is cross-sectional and applies to two subgroups, and it does not show that a short shoe causes hallux valgus.
Three things that cost nothing:
- Measure the foot, do not trust the number, which varies from brand to brand, and recheck every few months during the growth spurt.
- A wide toe box and no heel for long hours. If the "nice" shoe is an occasion, let it remain an occasion.
- If the bump rubs, the problem is the stiff upper at that point, not the lack of an insole.
On footwear, and in particular the barefoot trend, everything is in barefoot shoes for children: what the studies really say.
Red flags: when it is not (only) hallux valgus
This list does not come from a guideline dedicated to juvenile hallux valgus: we have not found one. These are the signs for which, during an assessment, we stop reasoning about the shape of the toe and send the young person to the doctor.
- Pain that wakes them at night, or that is present barefoot and at rest. Hallux valgus pain is load and shoe pain: if it appears at rest, something else needs investigating.
- Hot, red swelling, with or without fever: a medical assessment the same day.
- Morning stiffness lasting more than 30 minutes, especially if it also involves the hands, knees or ankles: a picture to take to the paediatrician.
- Visible worsening in less than 3 months, or a marked deformity on one foot only.
- Significant onset before the age of 10: it is the age at which progression is fastest, and the answer is a paediatric orthopaedic assessment, not an insole bought online.
- Tingling, loss of sensation, giving way or tripping: these point beyond the foot.
- Skin breaking down over the bump: not a blister, a lesion that does not close within a week.
- Widespread hypermobility throughout the body, or a known connective tissue disease in the family.
And surgery?
It always comes up, usually with the phrase "they'll operate anyway, better now while they are young". Paediatric surgical literature says the opposite: reviews dedicated to juvenile hallux valgus agree in postponing the operation until skeletal maturity when possible, because of the high recurrence rate in young people. The study of the 57 feet says it already at the start: the surgical management of juvenile bunion has not had the same success as in adults.
The figures come from a French multicentre study of 18 patients under 18 (26 feet) operated on between 2010 and 2019 with three different techniques and followed for a median of 6.5 years: average angle improvement of 13.2 degrees, but complications in 31% and recurrence in 23%, with no differences between the techniques, nor depending on whether the growth plates were open or closed. A small, retrospective sample, but consistent with the rest.
One last number, from the Cochrane review: those dissatisfied at follow-up were between 25% and 33%, even when angle and pain had improved. It concerns trials carried out largely in adults, but the reminder holds: surgery is done for pain that does not otherwise resolve, not for the appearance of the foot in a sandal.
What we can do
Let us say it plainly: we do not straighten your child's hallux valgus, and nobody can do so without an operation. If anyone promises it with a splint, a course of manipulations or daily gymnastics, they are selling you something that the studies have never seen happen.
What we can do is understand where the pain comes from and whether the picture is compatible with hallux valgus or deserves something else, look at how they walk and how the forefoot is loaded, and build a programme around their real load across school, sport and hours on their feet. And give you a clear answer to the real question: whether an orthopaedic assessment is needed now or not.
With Ri-Hub Junior you start with a free twenty-minute introductory consultation by video call with a physiotherapist registered with the Albo who works with children and teenagers: you show us the foot, how they walk, and the shoes they actually wear. From age 11 to 18 the sessions are the standard ones, 29,90 €.
Two limits, stated up front rather than after. If the signs in the list above appear, the right place is the doctor. And complex neurological and neuromuscular conditions require in-person assessment: we do not follow them online.
In three lines
Juvenile hallux valgus is largely hereditary, affects about 3.5% of fourteen-year-olds, and depends on the shape of the joint surface, not on how the young person holds the toe. Insoles, spacers and night splints have not been shown to stop its progression: in the only randomised trial on children, both groups got worse, the treated one slightly more. What can be improved is the pain, the shoe and the way the foot works, and since after the age of ten the deformity progresses little, you have time to do it calmly.
Sources
- A controlled prospective trial of a foot orthosis for juvenile hallux valgus: The Journal of Bone and Joint Surgery (Br), 1994
- Interventions for treating hallux valgus (abductovalgus) and bunions: Cochrane Database of Systematic Reviews, 2004
- Effectiveness of Nonsurgical Interventions for Hallux Valgus: A Systematic Review and Meta-Analysis: Arthritis Care & Research, 2022
- Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment: Foot & Ankle International, 1995
- Hallux valgus inheritance: pedigree research in 350 patients with bunion deformity: The Journal of Foot and Ankle Surgery, 2007
- High heritability of hallux valgus and lesser toe deformities in adult men and women: Arthritis Care & Research, 2013
- The prevalence of pain and deformities in the feet of adolescents. Results of a cross-sectional study: Zeitschrift für Orthopädie und ihre Grenzgebiete, 2004
- Reconceptualizing the Juvenile Bunion: Journal of Pediatric Orthopaedics, 2023
- Hallux valgus interphalangeus is more common in juvenile-onset hallux valgus than in adult-onset hallux valgus: Journal of Orthopaedic Surgery and Research, 2024
- Natural progression of radiographic indices in juvenile hallux valgus deformity: Foot and Ankle Surgery, 2019
- Juvenile hallux valgus. A conservative approach to treatment: The Journal of Bone and Joint Surgery (Am), 1992
- Juvenile hallux valgus: Comparison of three types of osteotomy and medium-term postoperative results: Archives de Pédiatrie, 2024
- Relationship of the Use of Short Footwear with the Development of Hallux Valgus in a Sample of Andalusian Schoolchildren: International Journal of Environmental Research and Public Health, 2021
- Juvenile Hallux Valgus: Foot and Ankle Clinics, 2021
- Pediatric hallux valgus: Foot and Ankle Clinics, 2014
Last source check: September 2026.
