The toes may not seem to have the same flexibility as the fingers but there are just as many tiny joints in the toes as there are in the fingers. This allows the toes to bend and straighten at will. Most people are not able to bend the toes individually as they are able to do with their fingers. However, there are conditions where the a single toe or several toes become abnormally bent and may stay in that position permanently if it is not surgically corrected. Three such conditions are known as hammer toe, claw toe and mallet toe.
Toe Bones and Joints
Hammer toe, mallet toe and claw toe are conditions where the toes are abnormally bent in different ways although there is some degree of overlap. It is important to understand the relevant anatomy of the toes to differentiate between these three conditions. Five thin long bones (metatarsals) extend across most of the foot to then articulate with thin shorter bones (phalanges) that make up the toe. All toes have three phalanx bones (phalanges) except the big toe which has only two.
These three bones from the metatarsals to the tip of the toes are known as the proximal, middle and distal phalanges, while the two phalanges of the toe are known as the proximal and distal phalanges. The joints between the metatarsal bones and phalanx bones are known as metatarsophalangeal (MTP) joint. The joints between the proximal and middle phalanges are known as the proximal interphalangeal (PIP) joints while the joint between the middle and distal phalanges are are known as the distal interphalangeal (DIP) joints.
What is hammer toe?
Hammer toe is a condition where the toe is bent downward at the proximal interphalangeal (PIP). It usually affects the second toe. There may also be a bend at the MTP joint thereby lifting the toe upwards.
What is claw toe?
Claw toe affects all toes simultaneously with exception of the big toe. Here the toes bend upward at the MTP joint but downward at the middle (PIP) joint and last (DIP) joint.
What is mallet toe?
Mallet toes is a condition where the toe bends downwards at the outermost joint (DIP joint). It usually only affects the second toe but the at times other toes may also be affected.
Causes of Abnormally Bent Toes
For toes to stay bent, the problem usually lies with the muscles and tendons that normally bend these toes at will. Tendons run from muscles to different bones. With the toes, one set of muscles and its tendons can bend or curl the toes while another set can straighten it and fan it outwards and upwards. However, sometimes the problem may be joint related.
Poorly fitting shoes are by far the most common cause of hammer, claw and mallet toes. It affects the balance of the muscles that control the toes. With the toes being forced to stay bent for long hours, the muscles and tendons can shorten over time. Eventually the toes do not straighten back to a normal position even once the shoes are removed.
An injury to the toe can increase the likelihood of these abnormally bent toe conditions to develop. Injuries like severely stubbing or jamming it, or even a history of a broken toe, may not immediately cause this abnormal bending but it increases the chances of it occurring later on.
There is some evidence that there may be a genetic predisposition to develop these abnormally bent toes. It is not a cause of the condition but rather a contributing factor that makes it more likely to occur in some people.
Inflammation of the joint (arthritis) can also contribute to hammer, claw and mallet toes. It is more likely to occur in severe cases of arthritis that affects these smaller joints of the toes, like with rheumatoid arthritis.
Nerve disorders that affect the nerve fibers supplying the foot and toes can also contribute to these toe conditions. It is more likely to arise with a stroke or in people with poorly managed diabetes where the nerves become damaged (diabetic neuropathy).
The abnormal bending of the toes may be the most obvious sign but there are other symptoms that also tend to occur. Firstly, trying to straighten the toe is difficult and often painful. Secondly corns and calluses also develop due to the increased pressure on parts of the toes as a result of the abnormally bent position. Sometimes this can form open sores (ulcers) especially in diabetics.
In mild cases, some people do not realize that the abnormal bending of the toes is a problem. They may find that their feet hurts significantly even after a just a short period of standing, walking or running. Another common complaint in these mild cases is that shoes may not seem to fit comfortably. Even when there are no corns, calluses or ulcers, there are often areas of redness and swelling of the affected toe(s).
Treatment For Bent Toes
If the toes are still flexible then it may be possible to correct the bent toe problem without surgery. However, once the bent toe becomes rigid then surgery is usually necessary.
First and foremost the regular footwear has to be changed. It is essential that footwear should have enough room to not push against the toes. Shoes that are too tight, pointy toe shoes and high heels are not suitable. It may also be necessary to use shoe inserts or foot pads which are specifically designed for a patient’s foot. Exercises may also be helpful in strengthening and straightening the toes over time, provided that toes still have some degree of flexibility.
Surgical procedures to straighten the toes is not the first choice of treatment. It is only considered when other conservative measures like changing footwear and exercises fail to straighten the toe. The procedures may involve operating on the tendon that is holding the toe in the bent position, or removing bone to allow the toe to straighten.