Lesser Toe Deformities

Mallet toe. Isolated DIPJ flexion with a normal PIPJ and MTPJ. It can be traumatic, an FDL rupture from stubbing the toe, which may present acutely with pain and inability to flex the DIPJ actively. Or it can be chronic, from tight footwear and FDL contracture, developing gradually under pressure from the toe box; it is usually flexible early.

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Flexible deformity. The toe corrects passively with manipulation and the joints keep their full range: the problem is a dynamic muscle imbalance without fixed contracture, and it corrects with ankle dorsiflexion on the modified Silverskiold test. It is reversible, so the aim is to preserve joint motion with soft-tissue balancing: tenotomy, transfer or lengthening.

Rigid deformity. A fixed capsular and tendinous contracture that does not correct passively, the result of chronic deformity with structural change, and the PIPJ may have secondary arthrosis. It needs bony correction by fusion, arthroplasty or osteotomy; soft-tissue releases alone will fail.

Crossover toe (second MTPJ instability). The plantar plate normally resists dorsal translation and hyperextension of the MTPJ. Crossover toe follows its attenuation or rupture, usually at the distal insertion on the base of the proximal phalanx, and the joint then hyperextends and deviates, medially (most common) or laterally. Early grades are reversible with soft-tissue repair; late grades have a fixed dislocation and secondary arthrosis that need arthroplasty or fusion.

Who it suits. Non-operative management is the first line for all deformities. It is indicated for:

• Asymptomatic or mildly symptomatic deformities
• Flexible deformities without significant pain
• Patients unwilling or unfit for surgery
• Early-stage crossover toe (Grade 0-I)

These are four parallel measures selected by what is causing the symptom, not four steps in a course. Footwear addresses the shoe pressing on the deformity, padding addresses the corn, taping addresses a flexible deformity only, and activity modification addresses the load. Test flexibility first - the push-up test tells you whether taping and splinting have any chance at all, because none of these measures can reverse a fixed contracture.

Footwear, the foundation. A wide toe box accommodates the deformity and reduces pressure, a low heel reduces forefoot pressure and FDL pull, soft uppers spare the dorsal corn, and adequate length stops the toes jamming into a flexed posture. Around 70% of mild cases improve with shoe modification alone, a high yield for an intervention that costs nothing surgical.

Padding and orthoses, for symptoms only. Dorsal pads protect PIPJ corns from the shoe, silicone or gel sleeves cushion the deformity, toe spacers separate the toes and reduce interdigital corns, metatarsal pads offload the metatarsal heads in metatarsalgia, and arch supports support the medial longitudinal arch in a flexible flatfoot. Padding relieves the symptom without correcting the deformity: it changes where the shoe presses, not where the toe sits. In an insensate diabetic foot a badly placed pad becomes a pressure point the patient cannot feel, so padding must be reviewed rather than simply prescribed.

Taping and splinting, for flexible deformities only. Buddy taping to the adjacent normal toe, dorsal night splints to hold IP extension, and plantar flexion taping to pull the MTPJ into plantarflexion. Taping works only while the deformity is still passively correctable and demands sustained compliance, so long-term efficacy is limited. It holds a position; it does not lengthen a contracted structure.

Activity modification. Avoid prolonged walking or standing, swap impact activities for swimming and cycling, use rest and ice for acute flares, and NSAIDs for the inflammatory pain of MTPJ synovitis. This reduces symptoms but does not alter the progression from flexible to rigid.

Absolute indications. These warrant surgical correction to prevent complications and restore function:

• Intractable pain despite a 3-6 month conservative trial
• Skin breakdown with chronic ulceration or infection risk
• Severe rigid deformity preventing shoe wear
• Progressive crossover toe with MTPJ subluxation or dislocation (Grade II-III)
• Functional impairment limiting walking or activities of daily living

Relative indications. These need shared decision-making, weighing the benefit against the risks of surgery and the recovery:

• Cosmetic concern in a motivated, healthy patient
• Recurrent corns requiring frequent debridement
• Moderate pain interfering with desired activities
• Prophylactic correction in a high-risk foot (diabetes, neuropathy)
• An associated procedure, such as correction during bunionectomy

The decision balances symptom severity, the flexibility of the deformity, patient factors and realistic expectations of the outcome.

The rule is to match the operation to the deformity and the tissue at fault: a rigid deformity needs bone surgery, a flexible one needs soft-tissue balancing.

Girdlestone-Taylor procedure. Indicated for a flexible claw toe with dynamic imbalance, a passively reducible MTPJ and no fixed PIPJ contracture. FDL is harvested, rerouted dorsally through the proximal phalanx and sutured to the extensor hood, which converts the deforming flexor force into a correcting one that plantarflexes the MTPJ and extends the IP joints.

Checking the transfer. After suturing, passively flex the ankle: the toe should extend without excessive MTPJ plantarflexion. Inadequate FDL release leaves a tether that prevents full correction. The MTPJ must be passively reducible pre-operatively or the transfer will fail: if it is not, add a capsule release or choose fusion. Several toes can be transferred at once in bilateral claw.

When the PIPJ is rigid. If the PIPJ does not passively extend, the transfer alone will fail, and a PIPJ resection arthroplasty or fusion is added to straighten the toe. The transfer corrects the MTPJ hyperextension and dynamic imbalance; the PIPJ procedure deals with the fixed contracture. Combined procedures are common in moderate-to-severe claw toes with mixed flexible and rigid components.

DuVries or modified Hohmann procedure. Indicated for a rigid hammer toe with a fixed PIPJ flexion contracture, a painful dorsal corn and shoe intolerance. Resecting the head of the proximal phalanx removes the bony prominence and allows the soft-tissue contracture to be released. The toe shortens slightly but ends straight and pain-free.

PIPJ arthrodesis. The gold standard for durable correction of the rigid hammer or claw toe, also used to revise a failed arthroplasty and for the young, active patient who wants a durable result. Cartilage is removed from both PIPJ surfaces, the raw bone ends are apposed and stabilised with intramedullary fixation, and the joint is fused in 15-25° of flexion. That mimics the natural cascade and gives a stable, pain-free toe in a functional position.

Choosing the fixation. The K-wire is the standard approach: inexpensive, simple and temporary, but it needs pin care, carries a risk of migration or infection, and the patient must keep the foot dry for 6 weeks. The headless screw is permanent and gives rigid compression with early weight-bearing and shoe wear, but costs more and needs more technical skill; it is preferred for young, active patients or when an early return to function is wanted. The systematic reviews under Outcomes agree that intramedullary implants achieve better radiographic union than K-wire but show no advantage in pain, satisfaction, foot function or complications, so choose on patient factors, surgeon preference and cost.

What goes wrong. Beyond the malunion and nonunion covered under Complications, over-shortening leaves a floppy toe that loses ground contact, and a migrating K-wire or prominent screw causes pain. Patient satisfaction is high, but no single fusion rate can be quoted.

Surgery is indicated for a symptomatic mallet toe: a painful distal corn, nail dystrophy, shoe intolerance. It is the simplest lesser toe deformity to treat: release it if flexible, fuse it if rigid.

FDL tenotomy for the flexible mallet toe. Releasing the FDL insertion removes the flexion force, and the toe assumes a neutral position with passive extension. It is a simple outpatient procedure with rapid recovery and low morbidity, and it works only for a flexible deformity:

• Local infiltration or ankle block
• Palpate FDL on the plantar aspect of the toe at the DIPJ
• A 2mm stab incision over FDL just proximal to the DIPJ crease
• Transect the tendon completely with a small (15) blade
• Passively extend the DIPJ, which should now move freely without resistance
• Close with a single 5-0 nylon suture or Steri-Strips; gauze and buddy tape

DIPJ fusion for the rigid mallet toe. Fusion in neutral or slight flexion (5-10°) is a permanent correction that removes the painful deformity and gives a stable distal toe. It sacrifices DIPJ motion, but patients have minimal functional limitation from a fused DIPJ, and the procedure is reliable and well tolerated:

• A small dorsal or lateral incision over the DIPJ (0.5-1cm), with minimal dissection and the extensor slip retracted
• Remove the cartilage from the distal phalanx base and middle phalanx head with a rongeur or small burr
• Hold in neutral or 5-10° of flexion and pass a 0.045" K-wire from the tip of the toe across the DIPJ into the middle phalanx
• Cut the wire outside the skin for removal at 4-6 weeks; close with 5-0 nylon or Steri-Strips

Plantar plate repair and flexor transfer. Indicated for a Grade I-II crossover toe with plantar plate attenuation and MTPJ instability, where the deformity is reducible or partially reducible. The plantar plate is repaired to restore MTPJ stability, and FDL is transferred to the extensor hood to plantarflex the MTPJ and prevent recurrent hyperextension.

Why it is multi-level surgery. Crossover toe is multifactorial, and isolated plantar plate repair has a high failure rate. Durable correction combines plantar plate repair for structural stability, the flexor to extensor transfer for dynamic stability, a Weil osteotomy if the metatarsal is long, and collateral ligament plication if there is medial or lateral instability.

The problem. A clawing or hammering lesser toe with a dorsiflexed (hyperextended) MTPJ has a tight, contracted EDL and dorsal MTPJ capsule pulling the proximal phalanx up onto the metatarsal head. Correcting the PIPJ alone, by fusion or arthroplasty, leaves the toe cocked up at the MTPJ, and recurrence and metatarsalgia persist.

The release. Through the dorsal incision the EDL is Z-lengthened, or for a milder dynamic deformity tenotomised, leaving extensor digitorum brevis to extend weakly. A dorsal MTPJ capsulotomy follows, and the tight dorsal and collateral structures are released until the proximal phalanx reduces to neutral on the metatarsal head. It is the extensor-side counterpart of the plantar plate and flexor work.

Where it fits. It is added to a PIPJ procedure whenever the MTPJ is hyperextended. A rigid MTPJ that will not reduce after release needs a shortening (Weil) metatarsal osteotomy or MTPJ arthroplasty instead. Getting the MTPJ to sit neutral is what stops the corrected toe re-clawing.

Why the clawed toe ulcerates. In a neuropathic (diabetic) foot the clawed lesser toe loads two vulnerable areas abnormally: the tip of the toe, as the flexed toe pulps the ground, and the dorsal PIPJ, against the shoe. Loss of protective sensation lets these pressure points break down into an apical or dorsal neuropathic ulcer, a common precursor to osteomyelitis and amputation.

The procedure. A percutaneous flexor tenotomy releases FDL, and often FDB, with a needle or blade through a tiny plantar or medial stab wound at the base of the toe, under local anaesthetic in clinic. It removes the deforming flexor force, so the flexible clawed toe straightens, the tip lifts off the ground, the apical pressure is relieved and the ulcer can heal.

Evidence and caveats. In neuropathic feet flexor tenotomy heals apical toe ulcers and reduces their recurrence compared with offloading alone, with a low complication rate, and it is quick, cheap and repeatable. It works only for a flexible claw; a rigid toe needs a bony procedure. It is still an operation on an at-risk foot, carrying wound, infection and transfer-lesion risk, so vascular status must be adequate. It is one of the few lesser toe procedures done prophylactically rather than for pain.

Setting expectations. Do it before the operation. Lesser toe surgery reliably relieves pain in the cited series (see Outcomes), but the cosmetic result may be imperfect: expect mild swelling for 6-12 months, slight shortening of the toe and some stiffness. Perfect alignment and a completely normal appearance are unrealistic goals, and patients seeking cosmetic perfection may be dissatisfied despite a good functional result. The goal is a pain-free, functional toe that fits in a shoe.

Diabetic patients. Diabetes increases complication risk 3-5 fold, so monitoring must be vigilant:

• Extended non-weight-bearing for 2-4 weeks to protect the soft tissues
• Weekly wound inspection for infection and dehiscence
• Glycaemic control, targeting HbA1c under 7% for optimal healing
• Extended oral antibiotic prophylaxis (7-10 days)
• Perfusion monitoring, considering hyperbaric oxygen (HBO) if healing is marginal
• Education in visual inspection, because a neuropathic patient may not sense pain

Revision surgery. Revision has higher complication and failure rates, 70% success against 85% for primary surgery, and the patient should be counselled accordingly:

• Longer K-wire fixation (8 weeks instead of 6)
• Full weight-bearing delayed to 6-8 weeks
• Early scar massage and mobilisation to prevent adhesions
• Bone graft or BMP may be needed when revising a nonunion