Mallet, Claw and Hammer Toe
MALLET TOE
Synonyms and Keywords
Mallet toe, claw toe, hammer toe
What is a Mallet Toe?
Mallet toes are found in the DIPJ (distal interphalangeal joint) of the lesser four toes. Those four smaller toes are like fingers, with three bones separated by joints (the big toe has only two bones). Mallet toes occur when the joint at the end of the toes (nearest the nail) cannot straighten because of strain or injury, causing the toe to bend out of shape looking like a mallet.
A mallet toe diagnosis is indicative of the joint at the very end of the toe buckling, while a claw or hammer toe diagnosis involves abnormal positions of all three joints. The affected toe may be either flexible or rigid.
If you are suffering from a mallet or claw toe, it is most likely visibly deformed. There is often pain in the toe, and you may have difficulty wearing certain shoes, notice discomfort when walking and experience pain in other parts of the foot. In some cases, a blister like bursa forms over the joint, which can become inflamed causing bursitis. Excessive rubbing of the mallet toe against the top of the shoe can lead to more pain and the development of a corn. The tip of the toe is often turned down against the shoe causing pressure and discomfort.
Mallet toes can cause extreme discomfort, and can be aggravated if restrictive or improperly fitting footwear is worn for a prolonged period of time.
What Causes Mallet Toes ?
Your toes bend and straighten by the use of two muscles. The most common cause of mallet toes is shoes that force the toes to stay in a bent position for too long, restricting the muscles' ability to flex, and tendons to shorten, causing tightening and making it more difficult to straighten the toe. Compressive women's footwear is the most common shoe culprit.
Arthritis can also lead to mallet toes by causing inflammation in the joints, which prevent proper movement of the tendons and muscles.
There are some inherited foot defects such as flat feet and high arches that will put excessive strain on the muscles and tendons making them more susceptible to mallet deformity.
Diabetes is often a cause of mallet toe. Twenty five percent of diabetics will develop foot problems. Diabetic foot conditions arise from poor circulation and neuropathy, which can cause the muscles to become bent in mallet toe formation.
Neurological conditions that affect nerves and muscles, such as strokes, cerebral palsy and degenerative disc disease can also cause mallet toes, as can circulatory issues such as peripheral arterial disease.
Being bedridden for any length of time can contract the muscles if they're not being used, causing mallet toes to form.
A broken bone in the toe or foot may heal improperly or cause damage to the muscle, tendon or joint, forming a mallet toe.
Who Gets Mallet Toes?
Women who spend a lot of time wearing tight or ill-fitting shoes are most often susceptible to mallet toes. Tight fitting shoes cause muscles to lose their function for straightening the toes. Wearing tight shoes for long periods of time can also shorten the tendons and over time the muscles will not be able to fully straighten on their own, forming mallet toes.
Mallet toe deformities are also often caused by the biomechanical functions of the foot and hereditary conditions such as flat foot, high arch and pronation (turning inward), which can put excessive stress on the joints causing the buckling.
People who have broken their toe run the risk of developing a mallet toe.
People suffering from arthritis, brain, spinal cord or nerve injuries such as stroke, cerebral palsy and degenerative disc disease, poor blood circulation, diabetes and People suffering from injuries such as broken toes are at an increased risk of developing a mallet toe.
Are There Different Types of Mallet Toes?
There are two types of mallet toes:
- Flexible mallet toe: Still in the developmental stage, these mallet toes can be moved at the joint, maintaining some flexibility and ability to achieve a straight position. There is typically minimal to no pain involved.
- Rigid mallet toe: The misaligned joints become fixed in the deformed position and are always rigid. Stretching or moving will not cause the toe to straighten. There is often significant pain in the toe and in other parts of the foot, particularly the ball of the foot. The mallet toe will restrict movement during walking and put more stress on the ball of the foot. Fitting into shoes can be a problem due to the bulging joint rubbing on the toe box of the shoe.
What are the Symptoms of Mallet Toes?
Deformed shape: Mallet toes exhibit a deformed, bulbous curve at the end of the toe, causing a mallet-like appearance.
Pain and stiffness: There will commonly be pain in the toe joint and difficulty moving the toe, sometimes causing difficulty walking. Cramping and pain in other toes, areas of the foot and the leg are often reported. Pain is also often present on the ball of the foot, which compensates for the toe.
Corns and calluses : The misshaped toe can often begin rubbing against the inside of your footwear causing rough patches of skin forming corns and calluses on the top of the toe. They may also form at the end of the toe. In more severe cases, corns can form on the sole of the foot from the pressure of the mallet toe.
Infections and Ulcers: Common in diabetic cases of mallet toe, ulcers and infections may be present on the affected toe.
How do you Diagnose Mallet Toes?
To diagnose mallet toes, the foot and ankle surgeon will examine the patient’s foot and look for signs and symptoms of a mallet toe.
Pathological exam : Observing the mis-shaped mallet toe typically makes the diagnosis. The doctor will ask questions about the pain or discomfort, if there is any difficulty wearing shoes and may want to watch you walk on the foot.
X-rays: Often your doctor will determine that x-rays may be necessary to get a better understanding of the extent of the deformity and what the best treatment is for the affected toe. This is more common with rigid mallet toes that may be a candidate for surgery.
How do you Treat Mallet Toes?
Forefoot problems causing pain should be given prompt attention. Ignoring the symptoms can aggravate the condition and lead to a breakdown of tissue, or possibly even infection. Treatment may take considerably longer to effect a cure, if it is not possible for you to avoid the causes of your mallet toe, such as neurological disorders. Additional causes, such as pressure and friction on the foot may also make it more difficult to heal a mallet toe.
Conservative Treatments
The first method of treating mallet toes begins with accommodating the deformity. The goal is to reduce friction and relieve pressure on the sensitive area.
- Padding: Prescribed gel pads from your doctor can help prevent irritation to corns and calluses that have developed from the mallet toe. Over-the-counter pads are also available.
- New Shoes: Avoiding shoes with pointed toes or high heels and shoes that are too short in the toe box will prevent the mallet toes from being forced against the front or top of your shoe. Comfortable shoes with a wide and roomy toe box and short to no high heels will offer more support and comfort to the toes.
- Orthotic devices: A custom orthotic device placed in your shoe may help control the muscle/tendon imbalance, bringing pain relief.
- Injection therapy : Corticosteroid injections are sometimes used to ease pain and inflammation associated with mallet toes. There are some risks with corticosteroids as they can cause damage and weaken the muscles, so your doctor will likely try other avenues first.
- NSAIDS: Over the counter oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil) or naproxen sodium (Aleve) may be recommended to reduce pain and inflammation.
- Splinting/strapping: Your doctor may apply splints or small straps to attempt to straighten out the toe. This is more common with flexible types of mallet toes.
Self-Care at Home
There are several at-home treatments you can use to help relieve your symptoms:
- High Toe Box Shoes: To prevent further irritation to the toe, shoes with a high and broad toe box (toe area) are recommended. Shoes such as Crocs, clogs or Birkenstocks may be enough of a change to allow pain free walking.
- Avoid high heels: Ladies, shoes do not make you beautiful, but being in pain can make you feel lousy. Opt for comfortable and supportive shoes so that without the pain your beautiful smile shows up from ear to ear.
- Toe props: These can be used to straighten the toe if it is still in the flexible state.
- Pads : Opt for the non-medicated pads that you can put over the toe to decrease the friction caused by the mallet toe.
- Stretching : Flexing and stretching the muscles and gently massaging may alleviate some of the pain and help relax the muscles and tendons.
- Epsom Salts: Soak the foot in a tub of warm water mixed with 1-2 cups of Epsom salts. Soak for thirty minutes, gently massaging the toe during the soaking.
- Treat your diabetes: Because so many people are suffering from diabetes, there are many other ailments erupting as a result of complications from the disease. If you actively manage your diabetic condition, you can address or avoid the complications that may come along with it.
Types of Mallet Toe Surgical Treatments
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In the very early stages where the toe is still flexible, the deformity can be corrected by relaxing the tendons. This is done through a small incision, which often doesn't require a stitch. An incision is made on the top of the toe and a small portion of the bone is removed. This allows the toe to relax and assume a straighter position. Following this procedure, the patient can return to comfortable shoes and resume normal activity.
- In some cases a flexible mallet toe will respond to a release of the flexor tendon. A cut releases the tight tendon allowing increased range of motion of the joint. The procedure may be performed in the office or as an outpatient procedure. Typical healing time can vary from several days to several weeks. Return to a loose fitting shoe such as a tennis shoe after approximately 3-4 weeks.
- The most common procedure involves resecting or removing the affected toe knuckle, releasing the flexor tendon. In more severe cases, tendons can be relocated to another area of the toe to flatten out the mallet toes and bones fused. The procedure may be performed under local or general anesthesia and in conjunction with a tendon release on the top of the foot. The combination of these procedures will cause the toe to lay flatter and avoid direct pressure from the shoe.
Prior to Surgery
You are about to have surgery. As you may already know, nutrition plays a very important role in proper healing. One of the most important benefits of proper nutrition is maintaining a right pH balance in your body. pH is the measurement of acidity and alkalinity. pH ranges are from one to fourteen with fourteen representing most alkaline. Seven is neutral. The most optimal pH level for humans is slightly more alkaline than acidic at around 7.36.
Undergoing surgery can increase acid levels in the body. Emotional and physical stress from both the surgery and recovery time changes your metabolism, which increases acid production. The use of both general and local anesthesia, pain medication, anti-inflammatory medications and other medications such as antibiotics will also introduce more acid to your system, lowering the alkalinity. This will delay healing and prolong recovery time.
To maintain your body's proper pH, keep yourself well hydrated prior to and after surgery. Water helps to dilute the acid build up in your body and release it through urination. Eating alkaline rich foods such as dark, leafy green vegetables will add alkalinity. Avoid acidic foods such as meats, fried foods, coffee (and other caffeinated drinks), carbonated beverages, cigarettes and alcohol.
Other pre-operative considerations:
- Many people may need medical clearance through their Primary Care Physician, especially if taking medications such as Coumadin.
- Stop using anti-inflammatory medication 5 - 7 days before surgery. These include: aspirin, ibuprofen (Advil, Motrin) and naproxen sodium (Aleve).
- Arrange for a ride home from surgery and for someone to look after you for at least the first 24 hours.
- Avoid long trips for at least two weeks after surgery.
- Avoid eating and drinking anything after midnight the night before surgery.
Day of Surgery
Most foot and ankle surgeries are day surgeries, which means you will go home the day of surgery. You will generally be given a local anesthetic and anesthesia. After surgery you will receive pain medication and care instructions.
Post-op Recovery
The best results and quickest healing is achieved when patients follow after surgery instructions.
- Keep your foot elevated as much as possible for the first week after surgery.
- Keep your foot dry for at least 2 weeks after surgery.
- One week after surgery you will have your dressing changed by coming to see your attending physician.
- The sutures will be removed after the second week.
- Your doctor will advise you when you can increase activities and put weight on the foot.
- Take pain and anti-inflammatory medications as prescribed by your physician.
- Vitamin C is important to heal scar tissue. It is vital in aiding in collagen formation. Take 4,000 mg spread out over each day in 500 mg doses taken for several days to several weeks after surgery.
- Omega 3 fatty acids, such as flax or fish oil, vitamin A and beta-carotene aid in the skin healing and lessen the appearance of scars.
How to prevent a mallet toe?
- Change your footwear, opting for shoes that do not rub the toes. Wear whoes that have a high toe box and are wide enough to prevent the pressure that can cause the deformity. Avoid wearing tight-fitting, narrow or pointed toe shoes, such as women's high heels or pumps.
- Prevent or treat arthritis, diabetes and neurological disorders to help reduce the risk of developing mallet toes.
- Avoid trauma to the toes, such as broken bones, which can cause mallet toes. In the case of a toe injury, seek immediate medical attention to make sure the bone is set to avoid the onset of mallet toes.
- Stretch and massage your feet regularly, especially after spending a long time in shoes.
- Regularly soak feet in Epsom salt baths, which relaxes the muscles and loosens the joints.
- Treat existing foot problems such as high arches or flat feet. Padding and orthotics for these conditions can prevent the development of mallet toes.
- Regularly visit your podiatrist to insure proper foot health.
