This blog deals with the most common foot condition:- Lesser toe deformity

What is it?

There are 4 types of lesser toe deformity

  1. Hammer toe
  2. Mallet toe
  3. Claw toe
  4. Retracted toe

Toe deformities especially hammer toe can be associated with hallux valgus (bunion) which affects the big toe. Patients may present with a pain free bunion and the first sign of problems is due to the hammer toes. This may be accompanied by pain in the ball of the foot. Muscle imbalance or systemic disease such as diabetes can often lead to changes in toe shape. If the condition is progressive and associated with a high arched foot (pes cavus), then an underlying neurological condition should be ruled out

  1. Hammer toe

With hammer toe, there is extension at the metatatarso-phalangeal joint (MTPJ) and flexion at the Proximal interphalangeal joint. The tip of the toe remains in contact with the ground on weight bearing

  1. Mallet toe

With mallet toe, there is flexion at the distal phalangeal joint only and the tip of the toe remains in contact with the ground on weight bearing. This may be associated with a longer toe, and flexes to “shorten” the toe length.

  1. Claw toe

With claw toe, there is extension at the Metatarso- phalngeal joint Flexion at the proximal phalangeal joint and flexion at the distal phalangeal joint. As the tip of the toe curls under, often the patient walks on the nail, leading to nail trauma and thickening (gryphosis)

  1. Retracted toe

With retracted toe, the same deformity occurs as with claw toe, but the tip of the toe is retracted from the ground.

How do I examine the foot?

The first and most important thing is to establish from the patient history, the duration of symptoms. Has this change in shape been gradual or rapid? Is there an underlying systemic disease process such as diabetes and, more importantly early loss of feeling (neuropathy)? In this case wasting of the small intrinsic muscles can lead to imbalance and changes in shape. More often a retraction will develop. Other conditions such as rheumatoid arthritis can lead to toe deformity.

Clinical examination should establish any pathology associated with the big toe such as hallux valgus.  In this case, there is a gradual shift of pressure to the ball of the foot weakening the ligaments (plantar plate) and tearing, leading to extension at the MTPJ and subsequent tightening of the flexor tendon leading to flexion at the PIPJ.

Range of motion of the small toe joints will determine if the deformity is flexible or has become fixed. Any previous current swelling at the MTPJ will provide information about capsular weakness

What treatment should I suggest?

Initial treatment should be conservative. Advice regarding footwear, especially wearing a shoe with deeper toe box can be helpful. Avoiding shoes with decorative stitching in the upper toe box can reduce irritation over the prominent joints.

Use of “off the shelf” pads such as silipos gel or orthodigital otoform splints moulded can be useful  

Silipos                           Otoform

If the patient is in a high risk group such as diabetic or rheumatoid, early referral should be considered.

Should simple conservative measures fail, referral for surgical intervention should be considered. In younger patients or in patients with flexible deformity, a simple release of the flexor tendon may be considered. This is a minimally invasive approach done under local anaesthetic. Recovery is 7-14 days.

Fusion of the PIPJ joint is a common procedure and involves either a wire placed externally across the joint or a tiny implant placed in the medullary canal to stabilise the joint. Recovery 4-6 weeks

An excisional arthroplasty (joint removal) can be considered as an alternative to fusion. This is often useful if a single toe is corrected, in cases where the toe still requires a natural bend, as fusion can make the “toe too straight”

Recovery 2-4 weeks.

What are the risks?

Short term risks include; infection, swelling and DVT (which is rare). Initial elevation of the limb in the first 2 weeks reduces swelling significantly.

Long term risks: floating toe, chronic swelling, flexion of adjacent joints (fusion of PIPJ can lead to mallet toe at DIPJ), Mal position and painful non- union with fusion can occur.

How effective is the surgery?

In an audit of 641 cases in my practice 92.4% were better following surgery.

What tests should I request?

X-rays are the best imaging modality to request.

Standard views

Dorso-plantar (DP) weight bearing. This view provides the best evaluation of the deformity

Lateral view weightbearing. This view provides information about the alignment of the hindfoot which may be affected by the condition

Medial oblique (MO). This view provides information about the joint spaces, the lesser metatarsophalangeal. Especially when evaluating osteoarthritis.