Hammer / Claw / Mallet Toe

Hammer, claw and mallet toes are deformities in which one or more of the smaller toes becomes abnormally bent at one or more joints. The bent toe rubs on shoes, causing pain, pressure and often corns. These deformities frequently occur alongside bunions. Treatment starts with footwear changes and padding, and surgery can straighten the toe if needed.

Each lesser toe has three joints: one at the base where it meets the foot, one in the middle and one near the nail. The three deformities are named by which joint is bent. They usually develop gradually. At first the deformity is often flexible (the toe can still be straightened by hand), but it may gradually become rigid.

What are the different types?

• Hammer toe: the toe bends downwards at the middle joint, so that the joint rises up. It most commonly affects the second toe.
• Claw toe: the toe bends up at the base and down at the middle joint, like a claw. It often affects all four lesser toes.
• Mallet toe: the toe bends down at the joint nearest the toenail. It most commonly affects the second and third toes.

A review in EFORT Open Reviews (Malhotra and colleagues) notes that hammer toe is often seen in people in their forties and fifties and is associated with bunions and inflammatory arthritis. Mallet toe is often attributed to tight shoes. Claw toe is commonly seen in neuromuscular disorders.

What are the symptoms?

• Pressure and discomfort when wearing shoes
• Pain when walking
• Corns or calluses over the bent joint or at the tip of the toe
• Stiff or arthritic toe joints

Bent toes tend to rub on shoes, on top of the toe, at the tip or both. The skin may simply be uncomfortable or can be rubbed raw. Bent toes may also rub on each other or on the big toe.

What causes these deformities?

The muscles, tendons and ligaments that normally hold the toe straight become unbalanced, so that one set pulls harder than the other. This can be caused or made worse by:

• Bunions (hallux valgus)
• Foot shape
• Injury
• Tight, narrow or high-heeled footwear

Associated conditions also include inflammatory arthritis, diabetes and neuromuscular disorders.

How are they diagnosed?

Diagnosis is based on examining the toe while standing and lying down to see which joints are bent and whether the deformity is flexible or rigid. The big toe and the joints at the base of the toes are checked for a bunion or instability. Weight-bearing X-rays show the position of the joints. An MRI scan is sometimes needed to look at the soft tissues.

Non-surgical treatment

Non-surgical treatment should always be tried first, as most patients respond to it. Options include:

• Wider shoes with a deeper, roomier toe box, avoiding high heels
• Toe sleeves, splints or pads to relieve pressure over the bent joints
• Custom orthotics to offload pressure under the ball of the foot
• Physiotherapy to stretch tight muscles and tendons
• Anti-inflammatory medication
• Cortisone injections for pain relief

Footwear modification may help ease symptoms and prevent the deformity from getting worse. Malhotra and colleagues note that inflammation of a toe joint's capsule may respond to a steroid injection.

When is surgery recommended?

If non-surgical measures fail, surgery can return the toe to a straighter position. Mr Hester will advise on the specific procedure for each case. The main types of operation are:

• Freeing up tight joints and tendons
• Moving one of the tendons that curl the toe to the top of the toe (tendon transfer)
• Removing bone from one or more joints and, where needed, fusing the joint straight

Any associated bunion or instability at the base of the toe may be corrected at the same time.

Most toe operations correct the problem for which they were done. Possible problems include: the deformity can come back, the toe may stay swollen for several months (in a few cases permanently), and stretching of the nerve in the toe can cause tingling, numbness or over-sensitivity. That nerve problem usually gets better after a few weeks but can be permanent.

Malhotra and colleagues note that few randomised controlled trials have compared treatments for lesser toe deformities.

What is recovery like?

Recovery after toe surgery typically takes around eight weeks. The skin and soft tissues heal over the first 10 to 14 days. Walking is possible in a post-operative shoe.

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of BOFAS and EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Malhotra K, Davda K, Singh D. The pathology and management of lesser toe deformities. EFORT Open Rev. 2016;1(11):409–419. PMID: 28461920. https://pubmed.ncbi.nlm.nih.gov/28461920/
2. Corns and calluses. NHS. https://www.nhs.uk/conditions/corns-and-calluses/
3. Bunions. NHS. https://www.nhs.uk/conditions/bunions/