Hammer toe, claw toe, mallet toe

Hammertoes occur when the smaller toes of the foot become bent and prominent. The four smaller toes of the foot are much like the same fingers in the hand. Each has three bones (phalanges) which have joints between them (interphalangeal joints). The toes form a joint with the long bones of the foot (metatarsals) and it is this area that is often referred to as the ball of the foot.

Normally, these bones and joints are straight. A hammertoe occurs when the toes become bent making the toe prominent. This can affect any number of the lesser toes. In some cases, a bursa (rather like a deep blister) is formed over the joint and this can become inflamed (bursitis). With time, hard skin (callous) or corns (condensed areas of callous) can form over the joints or at the tip of the toe.

What causes hammertoes?

There are many different causes but commonly it is due to shoes or the way in which the foot works (functions) during walking. If the foot is too mobile and / or the tendons that control toe movement are over active, this causes increased pull on the toes which may result in deformity.

In some instances trauma (either direct injury or overuse from walking or sport) can predispose to hammertoes. Patients who have other conditions such as diabetes, rheumatoid arthritis and neuromuscular conditions are more likely to develop hammertoes.

Are women more likely to get the problem?

It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity. It is common for patients to wear shoes that are too small and this can predispose to the problem.

Will it get worse?

At the start of the deformity, it is generally mobile which means that the toe can be straightened. However, with time, the joint become fixed or rigid. This can then affect the joint at the ball of the foot and, in severe cases, the joint capsule ruptures (tears) so that the joint becomes dislocated and the toe sits up in the air.

What are the common symptoms?

• Deformity / prominence of toe
• Pain
• Redness around the joints
• Swelling around the joints
• Corn / Callous
• Difficulty in shoes with deformity of the shoe upper
• Difficulty in walking
• Stiffness in the joints of the toe

How is it recognized?

Clinical examination and a detailed history allow diagnosis. X-rays are often not required but can help to evaluate the extent of the deformity and the degree of arthritis within the joint.

What can I do to reduce the pain?

There are several things that you can do to try and relieve your symptoms:

• Wear good fitting shoes with a deep toe box
• Avoid high heels
• Use a toe prop to straighten the toe if it is still mobile
• Wear a protective pad over the toe
• See a podiatrist

What will a podiatrist do?

If simple measures do not reduce your symptoms, there are other options:

• Advise appropriate shoes
• Advise exercises if the toes are still mobile
• Show you how to strap the toe in a corrected position
• Provide a splint or protection
• Consider prescribing orthotics
• Advise on surgery

The way in which your foot loads during walking can place increased stress on the ball of the foot and cause increased toe activity. Special shoe inserts (orthotics) can help to control foot movement. Whilst these are unlikely to resolve established deformity they may help reduce discomfort in the ball of the foot.

Will this cure the problem?

If the deformity is mobile, then this may help prevent progression although there have been no scientific studies to analyse the benefit. If the deformity is fixed, then orthotics will not cure the problem but may reduce the associated symptoms.

What will happen if I leave this alone?

Generally, the deformity becomes worse with time and slowly becomes fixed (stiff). This can cause discomfort in shoes. The position of the toe places increased stress on the ball of the foot and this can become painful. Corn and callous formation on the ball of the foot is not uncommon. In some cases, the metatarsophalangeal joint capsule ruptures, causing the toe to sit up in the air.

How can I cure the deformity?

The only effective way of correcting the deformity is to have a surgical operation.

How does the operation correct the deformity?

There are a number of different operations. However, the most common operations are:

• Tendon transfer
• Digital arthroplasty
• Digital arthrodesis

Tendon transfers involve taking the tendon from under your toe and re-routing it to the top of the toe so that the toe is pulled down. This can be used alone if the toe is mobile or in combination with the other two procedures. This can leave the toe a bit swollen and stiff.

Digital arthroplasty and arthrodesis involve the removal of bone from the bent joint to allow correction. An arthroplasty removes half the joint and leaves some mobility whilst an arthrodesis removes the whole joint and, following a period of time with a wire/pin protruding from the end of the toe, leaves the toe rigid.

In more severe cases, the tendon on the top of the toe and the joint at the ball of the foot need to be released to allow the toe to straighten. If there is severe stiffness at this joint, then the base of the bone at the bottom of the toe (phalanx) may need removing (basal phalangectomy) or the metatarsal shortened (Weil osteotomy).

Is it painful?

The nature of surgery means that there will be pain and swelling, usually worse the night after surgery. However, with modern anesthetic techniques and pain killers, this can be well controlled. The level of pain experienced varies greatly from patient to patient with some experiencing no significant discomfort.

Will I have to have a general anesthetic (be asleep)?

Not if you did not want one. Many of these procedures are performed perfectly safely under local anaesthetic (you are awake). Some patients worry that they may feel pain during the operation but it would not be possible to perform the operation if this were the case.

Will I have to stay in hospital?

No. As long as you were medically fit and have adequate home support, many patients are able to have this type of operation performed as day surgery and go home.

Are there a lot of complications?

There are risks and complications with all operations and these should be discussed in detail with your specialist. However, with most foot surgery it is important to remember that you may be left with some pain and stiffness and the deformity may reoccur in the future. This is why it is not advisable to have surgery if the deformity is not painful and does not limit your walking. A thorough examination of your foot and general health is important so that these complications can be minimized.

Although every effort is made to reduce complications, these can occur. In addition to the general complications that can occur with foot surgery, there are some specific risks with toe surgery:

• Persistent swelling which may be permanent
• Recurrence of deformity / corn (this tends to be more of a problem with the little toe)
• Regrowth of removed bone
• Residual pain
• Stiffness or flail (floppy) toe
• The toe may not sit on the ground – floating toe (there is an increased risk of this with arthrodesis)
• You may get discomfort in other parts of your foot during the recovery period. This generally settles.
• There is always a possibility that the deformity may return in later life.
• You may develop a mallet toe deformity in the long term

When will I be able to walk again and wear shoes?

In the majority of cases, you will able to walk with the aid of crutches within 2-4 days but you will remain somewhat limited for the first 2 weeks. Some patients are able to return to wider shoes within two weeks with 60% of patients in shoes at 6 weeks and 90% in 8 weeks. This period is longer for arthrodesis as shoes cannot be worn until the wire/pin has been removed (generally 3-6 weeks). Swelling generally starts to reduce at 6-8 weeks and the foot will be beginning to feel more normal at 3 months although the healing process continues for 1year.