Hallux Valgus and Preferred Shoe Types among Young Healthy Saudi Arabian Females
From the Faculty of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.
SS Al-Abdulwahab, RD Al-Dosry, Hallux Valgus and Preferred Shoe Types among Young Healthy Saudi Arabian Females. 2000; 20(3-4): 319-321
The human foot is a complex and sensitive structure which is used for weight bearing, propulsion and shock absorbing.1 The healthy foot, like the healthy body, needs proper nutrition, care and environment to perform these functions.2 Any alteration in the function of the foot causes changes in normal gait patterns and abnormal stress concentration.3 The foot is usually resigned to life within a shoe, which is often dictated by fashion. The foot's ability to function properly is influenced by the shoe that is worn. Inappropriate footwear can have an indirect but substantial ill effect on an individual's health, including affecting of one's gait.4,5
Foot disorders are caused mainly by biomechanical factors, infection and systemic diseases. However, the biomechanical basis of foot disorders is reported to be the most common problem in young people.6 The biomechanical basis of foot disorders is usually associated with low back pain, leg pain, abnormal weight distribution and abnormal gait.3 One of the most common biomechanical bases of foot disorders in women is hallux valgus (HV) deformity.
HV in young women is caused mainly by the types of shoes they wear.3,7,8 Changing customs and styles in footwear from clogs to fashionable high-heeled shoes have led to an increasing number of patients with the HV deformity in Japan.9 HV in China was found to occur 17 times more often in females who wore shoes than in those who did not.10 Many patients feel relieved of pain or a reduction in pain with modification of shoe wear.
Data regarding HV and type of shoes worn by the Saudi Arabian population have not been documented. Lifestyle, cultural and habitual activities are varied between communities, and are reported to influence anatomical and physiological performance.11,12 This makes it necessary for each community to document its own normal and abnormal physiological, biomechanical and anatomical changes, including HV.
Many women with mild HV are unaware of their potential foot problems and do not visit the clinic until the condition deteriorates, perhaps resulting in a deformity. This is perhaps an indication of a lack of foot health education.
Severe HV deformity is usually indicated for operative correction,13 and is usually painful and costly, and may cause complications or dissatisfaction.14-16 Women with mild HV deformity, however, are usually prescribed proper footwear and night orthoses for correction.17 Therefore, an early detection study of HV should be considered in any community of young females, particularly teens and females in their twenties. Such a study could help in preventing the complications of HV and improve the awareness of possible foot problems. Furthermore, documenting the distribution of foot disorders in any community may help in the planning of foot health education. Therefore, the purpose of this study was to determine the severity and distribution of HV and the type of shoes worn among young and healthy university-educated Saudi Arabian females.
Patients and Methods
One hundred healthy female students (mean age 22±9 years; height 157±6.1 cm; weight 57.9±11.9 kg) volunteered to participate in this study. The subjects responded to verbal announcements made at King Saud University, Faculty of Applied Medical Sciences. All were Riyadh residents, originally from different parts of Saudi Arabia, and claimed no known active foot problems or history of a pathological condition of foot or ankle.
HV was defined as a lateral deviation of the great toe accompanied by various degrees of deformity.18,19 Subjects were considered to have HV deformity if the HV angle exceeded 20 degrees.18,19 A goniometer was used to determine the angle of HV. Each subject sat on a standard straight back chair with hips, knees and ankles at approximately 90 degrees of flexion, with feet comfortably relaxed on the floor. To measure the HV angle, the pivot of the goniometer was placed on the middle point of the dorsal aspect of the first head of the metatarsal bone. The fixed arm of the goniometer was then placed on the longitudinal line of the first metatarsal bone, while the movable arm was placed on the longitudinal line of the great toe.16,19 The right and left feet of each subject were tested. Test-retest reliability of the above procedure was established in our laboratory (r=0.71).
Subjects were asked to describe the shoes that they most frequently wore for the previous six months during the daytime. They were then asked to select from a list of shoe types the particular type that best described their shoes:
1. Leveled sole with wide round toe box.
2. Leveled sole with narrow/pointed toe box.
3. Normal heel height (1-1.5 inch) with wide round toe box.
4. Normal heel height (1-1.5 inch) with narrow/pointed toe box.
5. High heel with wide round toe box.
6. High heel with narrow/pointed toe box.
The existence of pain/tenderness was determined by asking the subjects if they experienced pain/tenderness in the medial eminence and/or the first metatarsophalangeal joint during daytime while wearing shoes. The subjects responded either yes or no. Pain/tenderness was defined as any uncomfortable feeling in the medial eminence and/or the first metatarsophalangeal joint that interrupted or modified standing and walking.
Results
Our results showed that 39% of the participants had bilateral HV, with mean HV angle of 26.8±2 degrees in the right foot, and 24.9±3 degrees in the left foot. None of the subjects had unilateral HV (Table 1). The four shoe types most frequently worn by the participants were: leveled sole with wide, round toe box; leveled sole with narrow/pointed toe box; normal heel height with wide, round toe box; and normal heel height with narrow/pointed toe box. Thirty of the subjects (77%) who had HV wore normal heel height with narrow/pointed toe box, and the remaining nine subjects (23%) wore leveled sole with narrow/pointed toe box. The majority of participants without HV wore either leveled sole or normal heel height with wide, round toe box (Table 2). Only 20 of the 39 subjects who had HV reported pain or tenderness in the feet (Table 3).
Discussion
This study showed that 39% of participants had HV. It is not clear what caused such a large percentage, however, the type of shoes worn has been reported to be one of the causes of HV.3,7,8 Fashionable high-heeled shoes resulted in an increasing number of female patients with the HV deformity in Japan.9 In China, HV was found to occur 17 times more frequently in females who wore shoes than in those who did not.10 Furthermore, many acquired foot disorders in women result from the type of shoes they wear.3 It is, therefore, possible to conclude that the type of shoes worn by the participants with HV in this study is also the cause for HV. All participants with HV frequently wore shoes with narrow/pointed toe box which, as reported, displace the great toe laterally.3,8,19 The participants in this study who were without HV were found to wear shoes with round, wide toe box. This could support the assumption that shoes with narrow/pointed toe box cause such deformity. Therefore, shoes that provide plenty of room in the toe box should be encouraged. Not only should high-heeled shoe with narrow toe box be considered as one of the causes of HV,9,20 but also any shoe with narrow/pointed toe box.
Table 1. Number of subjects with and without hallux valgus and the HV angle in degrees (mean±SD) for both feet.
|
|
Without HV |
With HV |
|
Subjects (n=100) |
61 |
39 |
|
HV angle (°) |
||
|
Right |
9±5 |
26.8±2 |
|
Left |
12±4 |
24.9±3 |
Table 2. Types of shoes worn among participants.
|
Shoe types |
Subjects |
|
|
Without HV (n=61) |
With HV (n=39) |
|
|
Leveled sole with wide round toe box |
30 |
0 |
|
Leveled sole with narrow/pointed toe box |
6 |
9 |
|
Normal heel height with wide round toe box |
22 |
0 |
|
Normal heel height with narrow/pointed toe box |
3 |
30 |
|
High heel with wide round toe box |
0 |
0 |
|
High heel with narrow/pointed toe box |
0 |
0 |
Table 3. Distribution of pain/tenderness among subjects with HV deformity and the HV angle (in degree) for subjects with symptomatic and asymptomatic HV.
|
|
With pain and tenderness |
Without pain and tenderness |
|
Subjects with HV (n=39) |
20 |
19 |
|
HV angle (°) |
||
|
Right |
26±10 |
26±9 |
|
Left |
25±4 |
23±7 |
Although the background of the participants in this study was medical sciences, foot problems existed in 39%. This may indicate a need for foot health education to be taught in class. It has been reported that peak pressures under the first, second and third metatarsal heads in feet with HV are greater than those in the normal feet.21 More peak pressure on the first metatarsophalangeal joint in asymptomatic patients with HV than normal subject during normal gait has also been reported.22 Such changes in foot pressure are reported to impair foot function and cause foot pain.3 This is an indication that the physical performance of the 39% of the participants in this study could be affected, perhaps further developing in a future physical impairment or disability, which may affect their future work performance. Therefore, proper footwear and night orthoses should be prescribed. This has been reported to correct mild HV deformity.17
Pronation of the big toe usually results if the HV angle exceeds 30 to 35 degrees. This may cause flexion contracture of the interphalangeal joint,23 creating more complications. Limited range of motion of the metatarsophalangeal joint has been reported to severely impair foot function, change gait patterns and cause pathological changes in the joint.24 Since the HV angle of the participants in this study was less than 30 degrees, early intervention measures could be considered to prevent further complication.
In the field of rehabilitation, HV associated with pain is considered a cause for physical disability. The mild HV is usually managed with specific foot exercise, pain relief with physical modalities, muscle re-education by electrical stimulation and proper footwear.25-27 Although the conservative rehabilitation program for patients with HV has no complications and costs less than surgical management, patients with HV are rarely seen in rehabilitation departments in Saudi Arabia. The reasons are unclear, but may be due to the fact that general practitioners and orthopedic surgeons generally do not know what rehabilitation programs to prescribe for HV deformity, or it may be that patients are just not interested.
The HV angles in this study for both symptomatic and asymptomatic subjects with HV were less than previously reported in subjects around 47 years of age.18This may suggest that the HV angle increases with age. This study represented only a small percentage of the Saudi Arabia female population. The degree of weight bearing on foot during testing of HV angle was not considered in the current study. Despite this, a slight increase in the HV angle may occur with massive weight bearing.
In conclusion, foot health education should be emphasized in medical science classes. Further studies should be conducted to determine the effects of various HV angles and the associated degree of pain on physical performance, and the concentration level of female doctors, nurses and other allied health specialists during working hours.
References
1. Beesley R. A brief insight into the anatomy of the foot and ankle. Chiropody 1990:79-88.
2. Harkless L, Krych ST. Handbook of common foot problems. New York: Churchill Livingstone Inc., 1990.
3. Silfverskiold J. Common foot problems: relieving the pain of bunions, keratoses, corns and calluses. Postgrad Med 1991;89:183-8.
4. Robbins S, Gouw GJ, McClaran J. Shoe sole thickness and hardness influence balance in older men. J Am Geriatr Soc 1992;40:1089-94.
5. Robbins S, Waked E, McClaran J. Proprioception and stability: foot position awareness as a function of age and footwear. Age Ageing 1995;24:67-72.
6. Neale D. Common foot disorders: diagnosis and management. 1st edition. New York: Churchill Livingstone Inc., 1981.
7. Coughlin MJ. Hallux valgus. J Bone Joint Surg 1996;78a:932-66.
8. Smith E, Helms W. Natural selection and high heels. Foot Ankle Int 1999;20:55-7.
9. Kato T, Watanabe S. The etiology of hallux valgus in Japan. Clin Orthop 1981;157:78-81.
10. Sim-Fook L, Hodgson AR. A comparison of foot forms among the non-shoe and shoe-wearing Chinese population (abstract). J Bone Joint Surg 1958;40:1058-62.
11. Al-Abdulwahab S. The effects of aging on muscle strength and functional ability of healthy Saudi Arabian males. Ann Saudi Med 1999;19:211-5.
12. Abdulwahab S, Al-Mogren N. The spinal flexibility of Saudi Arabian healthy female children: normative values. Med Sci Res 1996;24:213-4.
13. Kelikian H. Hallux valgus, allied deformities of the forefoot and metatarsalgia. Philadelphia: W.B. Saunders, 1965:241.
14. Fokter S, Podobnik J, Vengust V. Late results of modified Mitchell procedure for the treatment of hallux valgus. Foot Ankle Int 1999;20: 296-300.
15. Schwitalle M, Karbowski A, Eckardt A. Hallux valgus in young patients: comparison of soft-tissue realignment and metatarsal osteotomy. Eur J Pediatr Surg 1998;8:42-6.
16. Katchis S, Smith R. Forefoot disorders. Curr Opin Orthop 1995;6:7-12.
17. Goldner JL, Gaines RW. Adult and juvenile hallux valgus: analysis and treatment. Orthop Clin North Am 1976;7:863-87.
18. Ito H, Shimizu A, Miyamoto T, Katsura Y, Tanaka K. Clinical significance of increased mobility in the sagittal plane in patients with hallux valgus. Foot Ankle Int 1999;20:29-32.
19. Palastanga N, Field D, Soames R. Anatomy and human movement: structure and function. 2nd edition. Oxford: Butterworth and Heinemann, 1994:563.
20. Chen BX. Treatment of hallux valgus in China. Chin Med J (Engl) 1992;105:334-9.
21. Yamamoto H, Muneta T, Asahina S, Furuya K. Forefoot pressures during walking in feet afflicted with hallux valgus. Clin Orthop 1996; 323:247-53.
22. Corbett M, Abramowitz A, Fowble C, Rask B, Whitelaw G. In-shoe plantar pressure measurement of the first metatarsophalangeal joint in asymptomatic patients. Foot Ankle 1993;14:520-4.
23. Myerson M, Komenda G Results of hallux valgus correction using an extensor hallucis brevis tenodesis. Foot Ankle 1996;17:21-7.
24. Nawoczenski D, Baumhauer J, Umberger B. Relationship between clinical measurements and motion of the first metatarsophalangeal joint during gait. J Bone Joint Surg 1999;81a:370-6.
25. Daniels L, Worthingham C. Therapeutic exercise for body alignment and function. 2nd edition. Philadelphia: W B Saunders, 1977:92-3.
26. Kitchen S, Bazin S. Clayton's electrotherapy. 10th edition. London: WB Saunders, 1996:276-86.
27. Kahn J. Principles and practice of electrotherapy. 3rd edition. New York: Churchill Livingstone, 1994:75-105.
Print version 
Plain text 
