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BASICS

Description

  • Hammer toe: plantar flexion deformity of the PIP joint ± hyperextension of MTP and DIP joints.
  • Claw toe: plantar flexion of PIP and DIP with MTP hyperextension.
  • Mallet toe: plantar flexion of DIP only.
  • Deformities can be flexible, semirigid, or fixed.

Epidemiology

  • Most common lesser toe deformity.
  • Second toe most commonly involved.
  • Female predominance (2.5:1 to 9:1).
  • Blacks affected more than whites.
  • Prevalence: 1–20% in various populations.
  • Incidence increases with age and duration of deformity.

Etiology and Pathophysiology

  • Congenital or acquired.
  • Acquired forms:
  • Flexor stabilization (common in pes planus/pronated foot).
  • Extensor substitution (common in pes cavus).
  • Flexor substitution (less common, pes cavus).
  • Muscle/tendon imbalance between EDL and FDL at MTP and PIP joints.
  • Contributing factors:
  • Toe length discrepancy.
  • Narrow footwear.
  • MTP joint synovitis and plantar plate elongation.
  • Rheumatoid arthritis.
  • Other: trauma, neuromuscular diseases, improper shoes.

Risk Factors

  • Pes cavus, pes planus.
  • Hallux valgus.
  • Metatarsus adductus.
  • Ankle equinus.
  • Neuromuscular disease.
  • Trauma.
  • Ill-fitting shoes.
  • Inflammatory joint diseases (RA).
  • Diabetes mellitus.

Prevention

  • Proper footwear with wide, deep toe boxes.
  • Pressure-dispersive footwear.
  • Toe strengthening exercises.
  • Control inflammatory joint diseases.

Associated Conditions

  • Hallux valgus.
  • Cavus foot.
  • Flat foot.
  • Metatarsus adductus.
  • Dorsal callus formation.

DIAGNOSIS

History

  • Onset, location, progression of deformity.
  • Pain characteristics and functional impairment.
  • Shoe and hosiery habits.
  • Neurologic symptoms.
  • Prior treatments.

Physical Exam

  • Observe MTP hyperextension, PIP flexion, DIP position.
  • Assess flexibility (weight-bearing and non-weight-bearing).
  • Inspect for skin changes: callus, ulcers, bursae.
  • Palpate for tenderness.
  • Drawer test for MTP stability.
  • Examine web spaces for neuroma.
  • Neurovascular exam.

Differential Diagnosis

  • Claw toe.
  • Mallet toe.
  • Overlapping fifth toe.
  • Interdigital neuroma.
  • Plantar plate rupture.
  • Arthritis (RA, psoriatic).
  • Fracture, exostosis.

Diagnostic Tests

  • Labs/imaging as indicated to rule out arthropathies.
  • Weight-bearing X-rays (AP, lateral, oblique) of affected foot.
  • MRI or bone scan if osteomyelitis suspected.
  • Nerve conduction studies if neuropathy suspected.
  • Doppler if circulation compromised.

TREATMENT

General Measures

  • Goal: relieve symptoms, restore function.
  • Mild/asymptomatic cases may not require treatment.

Conservative

  • Shoe modifications (wide/deep toe box, avoid heels).
  • Toe sleeves, orthodigital pads.
  • Metatarsal or crest pads.
  • Dynamic toe splints.
  • Toe-straightening orthotics or taping.
  • Debridement of hyperkeratosis; topical keratolytics.
  • Foot orthoses to correct biomechanics.
  • Physical therapy for toe strengthening and flexibility.

Medications

  • NSAIDs for pain and inflammation.

Surgical

  • Indicated if conservative fails or deformity severe.
  • Flexible deformities:
  • PIP arthroplasty or arthrodesis.
  • Flexor tenotomy (for reducible/mallet toe).
  • Extensor tendon lengthening/tenotomy.
  • Flexor tendon transfer.
  • Exostosectomy.
  • Implant arthroplasty.
  • Semirigid/rigid deformities:
  • PIP resection arthroplasty or arthrodesis.
  • Girdlestone-Taylor flexor-to-extensor transfer.
  • Metatarsal shortening (Weil osteotomy).
  • Middle phalangectomy.
  • Soft tissue releases.
  • Phalangeal base resection (Hoffman-Clayton procedure for RA mutilans).

ONGOING CARE

Follow-up

  • Post-op radiographs.
  • Weight-bearing precautions as per surgery.
  • Elevate foot to reduce swelling.
  • Return to normal shoes once healed.
  • Monitor for stiffness; physical therapy role unclear.

Patient Education

  • Swelling and discomfort may persist 1–6 months.
  • Molding of operated toe common.
  • Encourage roomy, comfortable footwear.

Prognosis

  • Conservative treatment usually relieves pain but deformity may progress.
  • Surgery corrects deformity and relieves pain reliably.
  • Recurrence possible if poor footwear continued.
  • Adjacent toes may develop deformities after surgery.

Complications

  • Persistent edema.
  • Recurrence.
  • Residual pain.
  • Stiffness.
  • Metatarsalgia.
  • Nerve palsy.
  • Flail toe.
  • Osseous regrowth.
  • Malunion/nonunion.
  • Infection.
  • Vascular compromise (ischemia, gangrene).

Clinical Pearls

  • Hammer toe = plantar flexion deformity of PIP.
  • Claw and mallet toes are distinct deformities.
  • Initial management is conservative.
  • Surgery if pain or deformity worsen.
  • Proper footwear critical to prevent progression.

References

  1. Shirzad K, Kiesau CD, DeOrio JK, et al. Lesser toe deformities. J Am Acad Orthop Surg. 2011;19(8):505-514.
  2. Thomas JL, Blitch EL IV, Chaney DM, et al; Clinical Practice Guideline Forefoot Disorders Panel. Diagnosis and treatment of forefoot disorders. Section 1: digital deformities. J Foot Ankle Surg. 2009;48(3):418.e1-418.e9.