Hammer, claw, and mallet toes are deformities that usually develop slowly, over many years. The muscles that control toe movement go out of balance, causing the toe to bend into an odd position at one or more joints. They may look odd or may hurt, or both.
- A hammer toe occurs when the longest toe (usually the second toe, next to the big toe) bends down toward the floor at the middle toe joint. The toe may bend up at the joint where the toe and foot meet, causing the middle toe joint to be raised slightly.
- Claw toe often affects all toes (except the big toe) at the same time, causing them to bend downward at the middle joints and at the joints nearest the tip, so that the toes curl down toward the floor. The toes bend up at the joints where the toes and the foot meet.
- A mallet toe often affects the second toe, but it may affect the other toes as well. The toe bends down at the joint closest to the tip.
These conditions can be painful and uncomfortable, especially while a person walks, as the toe presses and rubs against the shoe. These conditions almost always affect the 4 lesser (smaller) toes (those other than the big toe), and each condition involves a different toe joint or combination of toe joints.
The conditions are most often caused by tight, poorly fitting shoes, often in combination with a muscle imbalance. Several muscles work together to straighten and bend the toes. If a shoe forces a toe to stay in a bent position for long periods of time, the muscles tighten and the tendons shorten (contract). This makes it more difficult to straighten the toe. Eventually, the toe muscles cannot straighten the toe. These toe problems develop over years and are common in adults. Women have more of these problems than men because of the types of shoes they may wear, such as high heels.
Less common causes include:
- Problems in foot structure at birth. This may run in families.
- Joint diseases, such as rheumatoid arthritis.
- Brain, spinal cord, or nerve injury (especially in the case of claw toe). Examples include stroke, cerebral palsy, and degenerative disc disease.
- Not using your toe. Having to stay in bed for a long period of time may cause muscles to shorten (contractures). This may lead to toe problems.
- Poor blood flow to your feet (peripheral arterial disease).
- Having little or no "feeling" in your feet (peripheral neuropathy). This is common in people with diabetes.
- Injury, such as breaking a toe.
What are the symptoms?
The symptoms of hammer, claw, and mallet toes are deformity of the toe, pain and difficulty fitting into shoes. These toe joint deformities are usually easy to see by looking at the toes and comparing them to pictures of these deformities.
Hammer and mallet toes usually occur in your longest toe. This is usually your second toe, next to the big toe. Claw toe usually affects the lesser toes (those other than the big toe) at the same time. Mallet and claw toes may cause deformed toenails.
Pain, sores, calluses, or corns may occur at the:
- Upper part of the toe, where the raised joint rubs against your footwear.
- Tip of the toe. This almost always occurs with mallet or claw toes, and often occurs with hammer toe.
- Ball of the foot, which is the area of the bottom of the foot, between the arch and the toes.
Sores can become infected and lead to cellulitis or osteomyelitis, especially if you have diabetes or peripheral arterial disease.
In more severe cases, these toe problems may affect your balance and make it hard to walk. You may get calluses or corns where a bent toe presses against another toe or your shoe.
Fixed or Flexible Toe Joint Deformities
Toe joint deformities, such as hammer, claw, and mallet toes, may be fixed or flexible. In a fixed deformity, the toe joint cannot move normally. In a flexible deformity, some movement is possible. You may be able to move your toe with your hand but not be able to move it by itself, as you normally would. A flexible deformity may become fixed over time if you do not treat it.
Whether your deformity is fixed or flexible can also affect treatment options:
- A fixed deformity often requires surgery to be straightened.
- A flexible deformity can sometimes be straightened without using surgery. Stretching the joint or taping down the toe may work.
Diagnostic Exams and Tests
Your doctor will ask you questions about your symptoms and past health and do a physical exam to diagnose hammer, claw, and mallet toes. People rarely need tests, but your doctor may use an X-ray to assess the bone structure, especially if you are considering surgery.
Your doctor will ask questions about:
- Your symptoms, including when the problems started, what activities or shoes make them worse, and what other parts of the foot are painful. This includes asking about the shoes you wear at work and when participating in casual activities such as walking, and, how much time you spend standing or walking every day.
- The type of footwear you wear each day.
- Any previous foot problems or treatment for foot problems you have had.
- Other medical conditions that may be related. Such conditions include:
- Joint diseases (such as rheumatoid arthritis).
- Brain, spinal cord, or nerve injury (such as diabetic neuropathy).
- Shortened muscles (contractures).
- Poor circulation of blood to the feet (peripheral arterial disease).
During the physical exam, your doctor will look at your foot:
- While you stand, to diagnose the problem.
- While you sit, to check whether the joint deformity is fixed or flexible.
If surgery is the only remedy option for your foot situation, Dr. Pisarek will refer you to certified specialists for their expertise in this area; either a podiatrist or an orthopaedic surgeon for assessment and treatment options. If you are thinking about having surgery to correct your toe joint problem, you may need:
- An X-ray, to help determine what type of surgery (if any) would be most helpful.
- Blood flow testing (vascular testing), which may include Doppler ultrasound; if your condition suggests that blood flow to and from your foot is poor.
- Nerve conduction testing, if your condition seems to involve problems with nerve function in your foot. If this is the case, you may need a doctor who specializes in the brain, spinal cord, or nerves (neurologist).
How are they treated?
If you do not treat your toe right away, you are more likely to need surgery.
Chiropractic Methods May Help Too!
As the toes curl under, they also begin to stiffen up along with the rest of the foot. In early or mild stages of hammertoe, MedlinePlus, a service of the National Library of Medicine and the National Institutes of Health recommends manipulation of the foot to help keep the toes moving and flexible. Chiropractors can adjust the toes and other bones of the foot to keep the joints moving properly. Additionally, chiropractors and other health professionals can prescribe specific night splints that help correct the position of the toes over time.
- Decreasing Inflammation - As the joints stiffen and curl, pain and inflammation develop. Icing the area will help keep the pain down, and it is easy to do, as the toes are small and only take a couple of ice cubes and three to five minutes to ice completely.
- Stretching/Strengthening - Grabbing the toes and moving them back and forth gently will help stretch the toes, according to the AAOS. The Mayo Clinic recommends specific strengthening exercises, including picking up marbles with the toes, scrunching towels, and generally using the feet and toes to pick up items off the floor, as a means to correct the position of the toes.
You may be able to fix your toe with home treatment. Home treatment, including properly fitting footwear with lots of room for your toes, cushions, shoe inserts, toe splints, toe stretches, and over-the-counter pain relievers, is often all that is needed to relieve the discomfort. Doing these things will give the toe room to straighten, cushion the toe and hold it straight, and make the toe muscles stronger and more flexible. You can use medicine to treat pain.
Hammer toes and mallet toes require surgery only when non-surgical treatment fails. Claw toe is more likely to require surgery, but non-surgical treatment can be effective too. If your pain is too great or you cannot easily do daily activities, then consider surgery as a last resort. There is not much research on surgeries for these toe problems. Surgery may not completely return the toes to their normal positions, and toe joint problems may come back after surgery. Surgery is more likely if you continue to wear the types of shoes that cause toe problems.
The goals of treatment are to relieve pain so that your hammer, claw, or mallet toe does not limit your activities and to prevent the problem from getting worse. Even if your toes remain bent, your doctor will consider the treatment a success if he or she can relieve or reduce your pain enough to make you comfortable.
Initial and ongoing treatment:
It is usually best to use non-surgical treatment for hammer, claw, or mallet toes first. Treatment options for both fixed and flexible toe joint deformities include:
- Changing footwear. Shoes should be roomy, with wide and deep toe boxes (the area that surrounds the toes); low heels, and good customized orthotic arch supports. This provides room for your toe to straighten and prevents your toe deformity from rubbing or pressing against the shoe. Another option is to wear custom-made orthotics or shoes made for people who have foot problems. Footwear plays a large role in the development as well as the prevention of foot and toe problems such as bunions, calluses and corns, and hammer, claw, and mallet toes. Shoes that don't fit properly make these conditions worse and more painful, often leading to surgical intervention which may be avoided with proper fitting footwear and customized foot orthotics.
- A comfortable, well-fitted shoe offers you the best chance of:
- Relieving pain in the foot or toe that is caused by a deformity or joint problem.
- Preventing a foot or toe problem from developing or getting worse.
- Preventing a toe joint problem from returning after corrective surgery.
- Shoes that fit properly are key to both preventing and treating foot problems. You can develop a bunion, callus or corn, or hammer, claw, or mallet toe for a number of reasons, such as joint disease, genetic predisposition, or stroke. But your footwear can play a large part in how bad your foot condition becomes.
- If you have surgery for a foot problem, wearing shoes that fit properly will reduce your chances that the foot problem may come back (recur).
- Before shopping for shoes for your foot problem, ask your doctor for recommendations.
How do I find the right shoes?
For some people, the only acceptable option is a sandal or athletic shoe that doesn't rub on an existing bunion, callus or corn, or hammer, claw, or mallet toe. But most people will be able to find a shoe that causes little or no pain and allows them to function. Before shopping for new footwear, ask your doctor for recommendations specific to your needs.
Consider the following when shopping for footwear:
- Try on shoes at the end of the day, when your feet are at their largest due to normal swelling.
- If you have shoe inserts or orthotics, bring them with you to test them out in various shoes.
- Shoe size, especially width, may change with age. Having both feet measured ensures a good fit and identifies which foot is larger. Fit your shoes according to how the larger foot feels in the shoe.
- Stand during the fitting process to get an accurate sense of the fit.
- Walk around the store to make sure that the shoe fit feels right.
- If a shoe feels right but isn't your normal size, pay attention to how it feels. Ignore shoe size.
- You should not have to "break in" shoes if they fit properly.
- If a particular shoe fits snugly, the clerk may be able to stretch the shoe for a better fit.
When shopping for the right fit, look for:
- A low heel. Avoid high-heeled, narrow, or pointed-toe shoes. High-heeled shoes increase pressure on the front of the foot and on the toe joints. If you cannot avoid wearing pumps or high-heeled shoes, choose shoes with heels that are no more than 2 in. (5 cm) high.
- A wide and deep toe box (the area that surrounds the toes). There should be about 0.5 in. (1.3 cm) of space between your longest toe and the end of the shoe. You should be able to wiggle your toes in your shoes.
- A rigid yet cushioned heel counter that keeps your foot from slipping out of the shoe.
- A flexible sole that allows your toes to bend as you walk.
- A shoe that allows the ball of your foot to fit snugly into the widest part of the shoe.
- A lace-up shoe rather than a slip-on shoe. Athletic shoes are a good choice.
- Shoes that breathe when your feet sweat. Avoid plastic or vinyl shoes.
- Shoes that do not have seams that may rub against or irritate the skin over your foot problem.
- Wear sandals or soft-leather flat shoes or slippers, or buy an inexpensive pair of cloth shoes and cut a hole over the affected joint.
- Go barefoot as much as possible (or just wear a sock) unless you have diabetes or peripheral arterial disease or other conditions that decrease the feeling in your feet. People who have these conditions and have limited or no sensation in their feet are encouraged not to go barefoot, because unnoticed injuries to their feet are more likely to become infected.
- Wearing moleskin, pads, arch supports, or other customized orthotic shoe inserts. These products may cushion the toe or hold the foot and toes in a more comfortable position. They are better for treating a flexible deformity, but they also provide some relief for a fixed deformity. Your health professional can show you how to put pads or inserts in your shoe.
- Taking nonprescription pain relievers. Examples include acetaminophen, such as Tylenol, and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin , or naproxen. Check with your doctor before taking these medicines.
- Taking prescription pain relievers, which you may need if you have severe pain.
- Getting a corticosteroid injection which may reduce pain and inflammation for a period of time. But this does not change the joint structure causing the toe pain and is not commonly used. Your toe joint may be more painful for several days after the injection than it was before the injection.
- Caring for any calluses or corns on your toes or feet. Moleskin and other nonprescription treatments for corns or calluses may help relieve pain and burning. Never cut corns or calluses by yourself, because this can lead to infection. See home treatment for calluses or corns.
Non-surgical treatment specifically for flexible toe joint deformities includes:
- Taping or splinting hammer toes into place. Wrap tape under the big toe (or the toe next to the hammer toe), then over the hammer toe, and then under the next toe, gently forcing the hammer toe into a normal position. You may use a splint for the same purpose. Wrapping a toe does not straighten the toe permanently.
- Using toe caps or toe slings. These hold toes in a normal position, much like wrapping the toes with tape.
- Doing stretching exercises that help keep the toe joints flexible so that you can bend and straighten them. To do stretching exercises, gently pull on your toes to stretch the bent joints in the other direction, and hold the stretch for several seconds at a time. For example, if a joint bends up, gently stretch it down. Work on just one joint at a time. You should feel a long, slow, gentle pulling. Do this stretching several times in the morning and several times in the evening. To work on strength, try putting a towel flat under your feet and using your toes to crumple it and using your toes to pick up things, such as marbles. Your doctor, nurse, or physical therapist may be able to recommend more exercises.
Treatment if the condition gets worse:
If your hammer, claw, or mallet toe gets worse despite wearing properly fitting shoes and/or customized orthotic inserts, or if non-surgical treatment fails to reduce pain or discomfort, surgery may be an option. Generally, surgery is used only for severe toe deformities. Surgery may not completely return your toes to their normal positions, and toe joint problems may return after the surgery.
Surgical options may include one or a combination of the following:
- Phalangeal head resection (arthroplasty), in which the surgeon removes part of the toe bone.
- Joint fusion (arthrodesis), in which the surgeon removes part of the joint, letting the toe bones grow together (fuse).
- Cutting supporting tissues or moving tendons in the toe joint. This can relax the tension on the joint and allow the toe to straighten out.
- In rare cases, removing the toe (amputation) may be an option.
Surgeons often use surgery on the bones for fixed toe problems, and they move tendons for flexible toe problems.
What to think about:
Doctors generally advise everyone, especially athletes, children and people who have health problems such as diabetes, to take a conservative, careful approach when considering foot surgery.
If you have surgery for a toe problem, your surgeon may also operate on other toe joints to improve your symptoms.
Whether you have surgery generally depends on:
- The type and degree of your deformity. Claw toe may be more likely to cause pain and limit activities, and your doctor may suggest surgery. Hammer toe or mallet toe may respond better to nonsurgical treatment. Surgery is only used when pain and discomfort disrupt your daily life or other treatments have not worked.
- Whether the toe problem is fixed or flexible. With a flexible deformity, you have more options for treatment. For a severe fixed deformity, surgery may be the only solution when nonsurgical methods fail to control pain.
- Whether you have more than one toe problem. For example, if a bunion is pushing the second toe into a hammer toe position, surgery to correct the bunion can make room for the second toe. At the same time, surgery can correct the hammer toe.
You may consider surgery if you have hammer, claw, or mallet toes. But athletes, children, and people with health problems such as diabetes, rheumatoid arthritis, neuromuscular disorders, or circulatory problems generally have special considerations. This information may not apply to them.
Consider the following when making your decision:
- You should first try making changes in footwear and other nonsurgical treatments (such as using pads to cushion the painful area).
- You might consider surgery if you have:
- Severe pain in the toe that interferes with your daily activities and nonsurgical treatments have failed.
- A severely deformed foot that interferes with your daily activities.
- A fixed toe joint deformity. This condition generally requires surgery to relieve the pain and correct the deformity.
- The outcome of your surgery cannot be predicted. The success of surgery for hammer, claw, or mallet toes has not been widely studied. The specific outcomes and risks vary depending on things like the type of surgery, your surgeon's experience, and the severity of the deformity.
- Your expectations play a large role in how you feel about the results of surgery. If you want surgery to improve the way your foot looks, not necessarily to relieve pain, you may be less satisfied with the outcome.
A person typically has foot surgery as an outpatient, so you probably will not have to spend a night away from home. But other factors, such as your overall health, may make a hospital stay necessary.
Recovery from surgery often takes 4 to 8 weeks, although it may take longer especially if one has diabetes. How long it takes depends on the procedure you have done and how many problems your surgeon repairs. You may need follow-up X-rays. You may be able to walk on the affected foot right after surgery, possibly with a special shoe. How soon you can start wearing your own shoes depends on how quickly you recover.
Reference: WebMD Website
Call Dr. Pisarek at 416-633-3000 for a foot and gait analysis.