Small Toe Deformities: Overview

Small Toe Deformities: Overview

This video provides an overview of lesser, or small toe deformities. While there are many toe deformities, this discussion will focus on the most common types of toe deformities: mallet toe, hammer toe, claw toe, and crossover toe deformities. It is important to understand the basic anatomy of the lesser toes.

The lesser toes consist of toes 2 through 5 and do not include the big toe. The bones and the lesser toes are collectively referred to as phalanges. Each of the lesser toes is made up of 3 distinct bones. In addition to these bones, there are numerous soft tissues that help stabilize and maintain the position of the toes. These are a complex of ligaments around the base of the toe, multiple tendons, and 2 muscles that attach to the base of the toe. Together, these soft tissue structures maintain the stability of toe position.

The discussion will start with the 3 common lesser toe deformities that are similar. These are mallet toe, hammer toe, and claw toe. Mallet toe refers to an isolated flexion deformity where the end of the toe is in a bent position. Hammer toe is the most common deformity in the lesser toes. It is defined as extension at the joint at the base of the toe, near the metatarsal or foot bone, and a flexion deformity at the adjacent joint. A claw toe is like a hammer toe deformity, with the addition of a flexion deformity in the joint at the end of the toe. Claw toes typically involve all the lesser toes.

While many factors, such as family history and trauma, have been linked to these deformities, mallet and hammer toes are often linked to tight or ill-fitting shoes. Here is an example of a toe being squeezed into a tight shoe when the foot is in a tight shoe, an abnormal temporary position of the toes occurs, which places the base of the toe in an extended position while the 2 bones at the end of the toe are placed in a bent position. This puts the muscles at the base of the toe in a position where they are unable to assist in flexion, which places abnormal extensor forces on the toe. This causes the extensor and flexor tendons to become imbalanced. The extensors will have too much pull, which places the toe in an abnormal position.

While most people with claw toes do not have an illness that causes it, these deformities can be seen with neuromuscular or metabolic diseases. The risk of developing any of these 3 deformities increases with older age and is 4 to 5 times more likely in women compared to men. In societies where shoes are not typically worn, these deformities are rarely reported. Patients may present with pain in the toe or across the forefoot. It is also common to see a callus on the joints overlying the deformities, where the toes are rubbing in footwear.

The last deformity is a crossover toe deformity. This differs from the other deformities as the toe drifts horizontally instead of vertically. Most commonly, this is seen in the second toe as it drifts toward the big toe. In this image, the patient also has a hammer toe deformity, which can occur with a crossover deformity. Like the other deformities, an imbalance in the tissues surrounding the toes contributes to this problem. A hammer toe deformity may lead to a crossover deformity as it puts stress on the planter plate, the thick ligament at the base of the toe. If the planter plate tears or thins out, the joint may fall out of normal alignment. The collateral ligaments on the side of the toe cannot prevent this force, and they may weaken, causing the toe to move horizontally.

This deformity is also more common in women of advancing age. Often, patients report pain at the base of the toe in the region of the plantar plate. They may also have unusual spacing in between their toes. Health care providers will visually inspect the toes to assess for deformity, calluses, excessive spaces or crowding of the toes, or the inability of the toes to touch the ground when standing. They will also move the affected toes to assess if the deformities are flexible or fixed, which may help determine treatment.

A health care provider may directly test the mobility of the affected joint to assess for injury to the planter plate. This is called a vertical drawer test. While x-rays and MRIs are not necessary to make the diagnosis of any of these deformities, they are often done to rule out other causes of pain. On occasion, bloodwork may be ordered if an alternative diagnosis is being considered.