Basic Anatomy of the Toes
To understand and appreciate the hammer toe, mallet toe, and claw toe foot deformities, an understanding of the basic anatomy of the toes is important. There are three individual bones and two separate joints within each of your lesser toes (toes 2-5). These bones are the proximal, intermediate, and distal phalanges. Their respective joints are called the proximal interphallangeal joint and the distal interphallangeal joint. The big toe only has two bones (the proximal and distal phalanges) and one joint (the hallux (referring to the big toe) interphallangeal joint).
For a diagram depicting the osseous (skeletal) anatomy of the foot representing the relationship of these various bones, please visit: www.foottalk.com/anatomy.htm
Hammer Toe Deformity
The term hammer toe deformity (HTD) refers to the 'buckling' effect of the toes at the joint furthest from the tip of the toe (the proximal interphalangeal joint-between the proximal and intermediate phalanges). The buckling is a downward migration of the intermediate phalanx upon the proximal phalanx. This buckling affect makes the toe take-on the appearance of a 'hammer', and hence its name. There are varying degrees of the HTD. If the buckling affect is very mild, it is referred to as a 'flexible" HTD. When examining the flexible HTD, it is easily reduced (repositioned into normal position) with slight extension of the digit. The opposite type or level is referred to as a 'rigid' HTD. When examining the rigid HTD, the toe is not able to be reduced with any degree of extension of the digit. There are varying degrees of flexibility and/or rigidity that exist in-between these two deformities with varying terminology used, i.e. semi-flexible, semi-rigid, semi-reducible, non-reducible, etc.
Mallet Toe Deformity
The term mallet deformity (MTD) refers to this same buckling effect of the toes at the joint closest to the tip of the toe (the distal interphalangeal joint- between the intermediate and distal phalanges). This type of buckling affect makes the toe take-on the appearance of a 'mallet', hence its name. The MTD occurs only in digits 2-5 as there is only one joint within the big toe. The same types/levels of degrees of deformity exist with the MTD as exists with the HTD.
Claw Toe Deformity
The term claw toe deformity (CTD) refers to this same buckling effect which occurs at both the proximal interphallangeal and the distal interphallangeal joints. This type of buckling affect makes the toe take-on the appearance of a 'claw', hence its name. The CTD occurs only in digits 2-5, as again, there is only one joint within the big toe. The same types/levels of degrees of deformity exist with the CTD as exists with the HTD and MTD. HTD, MTD, and CTD's are just variations of the same type of buckling affect which occurs within the different joints of the toes. As described above, only the HTD occurs within the big toe, and it is referred to as a Hallux HTD}.
As the problems associated with all of these deformities are the same, they will all be addressed together.
The three most common patient complaints, or problems associated with all these deformities are: 1) pain; 2) difficulty with shoe gear: and 3) calluses or corns By far, the most common problem associated with these deformities is pain.
The most common type of pain syndromes which occurs with all three deformities is referred to as capsulitis and synovitis. Capsulitis is an inflammation of the 'capsule-like' tissues which encloses each of the joints described in the anatomical section above. Inside of each joint capsule is a fluid called synovial fluid (the motor oil of our joints), which becomes inflamed and causes synovitis. In addition, the tendon(s) and/or nerves associated with the toes may become inflamed and can lead to tendonitis and neuritis, respectively.
These pain syndromes are the direct result of increased friction and irritation caused by the misalignment of the bones of the toes.
Difficulty with shoe gear occurs due to the extra-space that these deformities take-up within patient's shoes. Obviously, women, and women's shoes, typically cause more problems due to style and fashion considerations. The narrower and higher the heel, the more potential problems that may occur}. However, many men, and women who wear very practical shoe gear, still have significant problems with these foot/toe deformities.
Calluses or corns are a very common problem that causes both pain and difficulty with shoe gear. A corn is just a common name referred to the particular type of callus related to HTD, MTD, and CTD's. Varying degrees of corns and calluses can occur with these deformities. Some patients develop large, thick corns on the top of their toes, but exhibit very little pain or problems with their shoes.
While other patients with these deformities develop very little to no callus formation whatsoever, but have significant pain and/or problems with their shoes.
The most important factors regarding the level and extent of problems associated with these deformities include (but are not limited to): 1) degree of flexibility or rigidity of the individual deformit(y)(ies); 1) age and sex of the patient; 3) type of shoe gear typically worn; 4) individual physical factors-weight/height/foot type, etc; 5) environmental factors-(extra)curricular activity/type/degree/frequency, etc.
Treatment of the HTD, MTD, and CTD
The level of treatment necessary for the successful management of these deformities depends primarily on what degree of problem(s) they create for individual patients.
The vast majority of HTD, MTD, and CTD's are relatively asymptomatic (pain-free) and are more of a cosmetic problem for many patients. Particularly women who may develop some degree of unsightly callus formation and/or the pigment discoloration that frequently occurs. This pigment discoloration is more readily evident in darker skinned individuals.
Asymptomatic (pain-free) callus formation and/or discoloration, in my opinion, should not be treated medically. Shoe modification, OTC corn medications or callus files, and/or skin-softening lotions are my recommendation when dealing with non-painful toe deformities such as hammer, mallet, and claw toes.
Deformities that cause pain and problems with shoe gear and ambulation are treated by a multitude of methods. Relatively mild conditions can be treated with a combination of shoe modification, accommodative padding, and the local debridement (removal) of corn and callus tissue. More severe conditions can be treated with the above plus the use of oral and/or injectible anti-inflammatory medications. The most severe conditions can be treated with surgical correction.
The standard surgical procedure use in the correction of these deformities is referred to as an arthroplasty procedure. The procedure involves the removal of the portion of bone that is causing the friction/irritation and pain. The procedure can be performed in an office operating room environment; however, I normally recommend the procedure be performed as an out-patient procedure in an operating room environment. This is due to patient comfort (with the use of IV sedation-not a general) and the lower risk of developing a post-operative infection.
After care involves the use of a surgical shoe for approximately 4-6 weeks depending on individual patient parameters. Occasionally physical therapy is recommended to reduce the pain and swelling associated with the healing process.