Toe deformities (hammered toes, mallet toes) are commonly caused by continuous pressure exerted by shoegear, a muscle imbalance in the foot as a result of flat or high-arched feet, traumatic injury to the toes, or systemic disease affecting the toe joints.

Anatomy

The anatomy of each toe is surprisingly complex for such a small and seemingly insignificant structure.  There are four groups of muscles that control each toe. Two tendons (extensor digitorum longus and extensor digitorum brevis) join on the dorsal aspect (top) of the toes, and insert into the middle and distal phalanges of each toe. On the bottom (plantar aspect) of the toes is a set of two flexor tendons that insert onto different bones of the toe. Each muscle stabilizes one of these bones in the toe and consequently contributes to the overall stability of each toe. The flexor digitorum longus muscle attaches to the bone at the end of the toe (distal phalanx) and the flexor digitorum brevis attaches to the middle phalanx. The proximal phalanx is stabilized by additional muscles called the lumbricales and interossei.

If there is an imbalance in the foot such as seen with abnormally flat feet, these smaller muscles can be overpowered by the larger flexor and extensor muscles.

The terminology for an excessively flat foot is a pronated foot.  In the pronated foot, the two flexor muscles can overpower the extensor muscles because the lever arm for the flexor pull is longer than in a foot with a normal arch. When the foot flattens it also lengthens, causing increased tension on the flexor tendons and a resultant pull on the ends of the toes. Likewise, the extensor tendons also have the ability to become contracted and exert an abnormal force on the toe.

A clawtoe, mallet toe or a hammertoe can result from this excessive flexor or extensor pull, depending on the level of muscle pull, which is anatomically termed the level of contracture. 

Signs and Symptoms

Hammertoes and clawtoes begin as a gentle although reducible bend in the toe, and may seem minor at first. However, if left untreated, they can become fixed deformities. In this contracted position, the inside of the shoe (toebox) rubs against the contracted joints, causing calluses to form on the top or ends of the toes. In certain patients, these corns and callosities can ulcerate or open and become problematic wounds.  When deformities reach this stage, the toes are usually fixed in a bent position and cannot be easily straightened.

A retrograde force or buckling effect is also exerted on the ball of the foot from the contracted toes.  The metatarsal heads form the ball of the foot. Calluses and ulcers can develop beneath these bones as well as anywhere on the sole of the foot. For this reason, it is important to treat hammertoes and clawtoes when they first begin as well as the forces that caused them to begin in the first place. 

Treatment

Treatment for hammertoes and clawtoes depends on the severity of the deformity. When the toes first start to buckle, they can be straightened easily through gentle pressure using pads and taping. Typically in this stage the problem that caused the toe contracture can be identified and corrected or minimized.  Often times the structure of the foot or the manner in which a patient walks is the culprit, and a podiatrist can fit the patient for custom-molded orthotics that provide a better arch for the foot and help the muscles work together. An orthotic is a specific device for controlling abnormal forces and mechanics of the foot during walking or running.

Without any treatment, the muscles and ligaments that attach to the toes begin to contract and stay contracted, which stiffens the toes in a bent position. Once these rigid deformities result they almost never revert to a more flexibile state that can be easily manipulated with taping, strapping, or orthotics alone. In these cases, surgery is usually necessary to relieve the pain associated with these deformities.

Surgery

Arthroplasty is a surgical procedure that removes the stiffened, contracted joint. In this procedure, the foot surgeon makes an incision along the toe and trims the head of the proximal phalanx. This usually allows the toe to straighten. Muscle and ligament rebalancing is part of the procedure, and the result is a semi-flexible, straight toe.

Arthrodesis is another option for treatment of hammertoe deformities, and involves fusing two bones together, typically the proximal and middle phalanges. The two bones can be fixed together with a removable pin. The pin remains in place for 6 weeks while the bones heal together in a straightened position.

Toe surgery, while seemingly benign, still demands that the patient remain in a surgical shoe until such time as the bones are healed and any pins are removed.

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