Eric J. Strauss, M.D. - Orthopaedic Surgeon
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Common Toe Deformities

Anatomically the foot is divided into the forefoot, mid foot and hind foot. The Forefoot has 4 small toes called phalanges and 1 large toe called the hallux or big toe. Phalanges have 3 bones and 3 joints, while the big toe has 2 bones and 2 joints. The mid foot and hind foot have different structures, which are responsible for bearing body weight and performing activities such as walking and running.

Toe deformities are common problems that occur due to abnormal positioning of the foot bones, inadequate biomechanics, and diseases such as arthritis affecting bones and tissues of the foot. Toe deformities not only affect the alignment of the bones, joints and tissues in the foot, but may also affect alignment of the weight bearing joints such as the hips or knees resulting in further problems. The most common toe deformities are hammertoes, claw toes, and mallet toes.

Causes

Toe deformities can be congenital, present at birth, or can occur later in life from wearing improperly fitted shoes or high heeled shoes. Certain diseases conditions such as diabetes, stroke, osteoarthritis, and rheumatoid arthritis affect the functioning of muscles and nerves and can cause tightening of ligaments or tendons resulting in these deformities.

In some cases, accidents or injuries can result in fractures and lead to toe deformities.

Signs and symptoms

The symptoms associated with hammertoe, claw toe and mallet toe are similar and include feeling pain while wearing shoes and having difficulty finding properly fitted and comfortable shoes. Improperly fitting footwear can result in hard skin outgrowths from high pressure and friction.

At the onset of the problem, the deformed toe is usually flexible, however, if left untreated it can become rigid and immovable requiring surgical treatment. Therefore, it is recommended to see your doctor for early treatment measures.

Characteristics of common toe deformities

In the case of Hammertoes, the toe is bent at the middle joint leading to curling of the toe resembling a hammer. Hammer toe is commonly seen in the second toe, but can affect other toes as well. Another related condition called a bunion is often seen along with hammertoe, and involves a bony outgrowth along the side of the foot at the base of the big toe.

Claw toes exhibit an upward bending of the toe joint at the ball of the foot, followed by the toe bending downward in a claw-like fashion, at the middle joint and sometimes end joint. Claw toe can occur in any toe except the big toe.

Mallet toe is similar to hammer toe except that the joint involved is the upper joint instead of the middle joint, giving the toe a mallet-like appearance at the end of the toe.

Diagnosis

Toe deformities are simply diagnosed by a physical examination of the toe and usually no diagnostic test is required. However, in cases where the physician suspects nerve involvement, then special tests may be ordered.

Treatment

Initially, toe deformities are treated by conservative treatment measures to restore or maintain walking ability, relieve pain, and also to delay progression of the deformity.

Conservative treatment includes wearing specially designed shoes with cushions or pads with an enlarged toe box area to prevent skin breakdown. You will be instructed to avoid wearing tight, narrow, or high heeled shoes. Splints or tape may be applied to reposition the toes, and regular toe stretching exercises are also recommended.

Surgical treatment is recommended if conservative treatment fails to relieve symptoms, or the deformed toes become rigid and immovable. The main objective of the surgery is to restore normal toe alignment and return the foot to normal pain-free function.

The surgical procedure is chosen based on the stability of the deformed toe, whether it is flexible or not.

If some flexibility exists in the toe, then the surgeon will make an incision over the deformed toe joint and realign the tendons and ligaments. Pins may be placed to keep the toe in position while healing. The incision is then closed with sutures and covered with a sterile dressing.

In cases where the deformity is rigidly fixed, then the surgeon will make an incision over the joint of the deformity, realign the tendons and ligaments, and also perform an osteotomy, removal of bone pieces. Pins are also inserted to keep the toes aligned while healing. Finally, the incision will be closed with sutures and covered with a sterile dressing.

Risks and complications

Apart from general complications linked with any surgical operation, other specific complications include inadequate correction of the deformity, and stiffness of the toe. Loss of blood supply to the toe and damage of the surrounding nerves is rare but may also occur.

Post-operative care

Apart from general guidelines given by the surgeon after any surgery, specific instructions following toe deformity surgery includes wearing a special post-op shoe for at least 2-6 weeks to prevent bending the operated toe.

Conclusion

Toe deformity is a condition where there is misalignment of the toe bones. The common toe deformities include hammertoe, claw toe, and mallet toe. Most toe deformities are flexible but if untreated they may become rigid and can only be treated by surgical methods. Treatment of toe deformities starts with conservative methods, but if no effective response is seen, then surgery is recommended.


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