Lesser Toe Deformities: Pathology and Management
Deformities of the lesser toes are a common condition often encountered in both clinical and surgical settings, with significant implications for mobility and quality of life. While these deformities may occur gradually or result from trauma, ill-fitting shoes and certain foot conditions like hallux valgus can contribute to their progression.
Anatomy and Function of Lesser Toes
The lesser toes, typically referring to the second, third, fourth, and fifth toes, are crucial for maintaining balance and facilitating efficient walking. Each toe is composed of three phalanges: distal, middle, and proximal, articulating with the metatarsal bones at the metatarsophalangeal joint (MTPJ). The muscles controlling the movements of the lesser toes include the flexor digitorum longus (FDL) and the flexor digitorum brevis (FDB), which work to flex the joints, and the extensor digitorum longus (EDL) and extensor digitorum brevis (EDB), which extend the toes. These muscles are critical for the toes’ ability to push off the ground during walking and running.
The windlass mechanism, described by Hicks in 1954, plays a pivotal role in foot biomechanics by leveraging the toes as a spring mechanism. This system helps absorb shock and aids in propulsion during the stance phase of walking, with the lesser toes playing a key role in distributing the load from the metatarsal heads to ensure even weight-bearing.
Pathology of Lesser Toe Deformities
Lesser toe deformities include claw toe, hammer toe, mallet toe, and crossover toe, each of which results from an imbalance in the forces acting on the toes. These deformities are often linked to metatarsalgia, hallux valgus, and inflammatory conditions such as arthritis or diabetes mellitus. Chronic instability in the MTPJ, often exacerbated by poor footwear choices like high heels, can lead to misalignments in the toe joints.
- Claw Toe: Characterized by hyperextension of the MTPJ with flexion at the proximal and distal interphalangeal joints (PIPJ and DIPJ), claw toe is often seen in conditions like neuromuscular disorders. Over time, the abnormal forces lead to the shortening of the intrinsic muscles, causing the toes to remain in a flexed position, which can make it difficult to properly weight-bear during walking.
- Hammer Toe: This condition typically affects the PIPJ, leading to a flexed posture at this joint. Often associated with hallux valgus or inflammatory arthritis, hammer toes result from imbalance in the muscle forces acting on the toe. The flexors become dominant, pulling the toe into a flexed position while the extensors fail to counteract this force. In some cases, the MTPJ may become hyperextended as the condition progresses .
- Mallet Toe: A mallet toe is defined by flexion at the DIPJ, usually resulting from pressure on the toe from tight footwear. This condition can be flexible initially but may become permanent as the joint structures, including the tendons and ligaments, tighten over time .
- Crossover Toe: Crossover toe is often seen in women, particularly those over 50 years of age. The deformity occurs when the toe shifts laterally or medially, often affecting the second toe, leading to overlap with adjacent toes. This condition is linked to hallux valgus and can cause discomfort and functional impairments .
Assessment and Diagnosis
A comprehensive assessment of lesser toe deformities involves reviewing the patient’s history, including any prior trauma, diabetes, or inflammatory conditions. Footwear, occupation, and family history should also be considered. Physical examination should focus on identifying callosities or pressure areas on the toes, and assessing flexibility in the MTPJ and PIPJ joints. The Lachman test for MTPJ instability is considered pathognomonic for joint dysfunction .
Imaging, including plain radiographs, MRI, or ultrasound, is used to assess the deformity and its impact on surrounding structures. In cases of suspected plantar plate tears or instability, MRI arthrograms may offer further insight .
Non-Operative Treatment Options
For many patients, non-operative treatments are effective in managing symptoms and preventing further progression of toe deformities. These approaches include:
- Footwear Modifications: Shoes with a wider toe box can reduce pressure on the toes and prevent exacerbation of deformities. High heels should be avoided.
- Padding and Toe Sleeves: Silicone pads and toe sleeves can protect pressure points and alleviate discomfort .
- Orthotics: Metatarsal off-loading insoles can help redistribute pressure from the metatarsal heads, reducing pain associated with metatarsalgia .
- Steroid Injections: Capsulitis and inflammation around the MTPJ can respond to corticosteroid injections, reducing pain and swelling .
Surgical Management
When conservative measures fail, surgery may be necessary to correct the deformity and restore function. Surgical goals include realigning the affected toe joints, stabilizing the MTPJ, and restoring balance between the flexors, extensors, and intrinsic muscles.
- MTPJ Instability: For claw and hammer toes, MTPJ instability should be addressed first, often through extensor release or lengthening, followed by capsulotomy or, in more severe cases, flexor-to-extensor tendon transfer .
- Osteotomy Procedures: Weil osteotomy, a commonly performed procedure for metatarsalgia and toe deformities, involves shortening the metatarsal to reduce pressure on the affected toe. Studies show good outcomes, with a reduction in callosities and improved pain relief post-surgery .
- Flexor and Extensor Tendon Transfers: Tendon transfers are frequently used for claw and hammer toes to restore balance and prevent recurrence. The flexor-to-extensor transfer, originally described by Girdlestone-Taylor, is particularly useful for correcting hyperextension of the MTPJ .
- Mallet Toe: For mallet toe, a flexor tenotomy is often effective in the early, flexible stages. In more severe cases, fusion of the DIPJ may be necessary .
- Crossover Toe: Crossover toes may require more complex soft-tissue releases and possibly osteotomies, such as the Weil osteotomy, to realign the affected toe. For advanced cases, a flexor-to-extensor transfer may be required .
Minimally Invasive Surgery
Minimally invasive techniques have become increasingly popular for treating lesser toe deformities. Procedures such as percutaneous flexor tenotomy and distal metatarsal metaphyseal osteotomies (DMMOs) offer reduced scarring, faster recovery, and less postoperative pain compared to traditional open surgery . However, these techniques require specialized training to avoid complications like nerve damage and tendinous injury .
Conclusion
Lesser toe deformities, while common, can lead to significant disability if not addressed appropriately. Treatment varies from non-invasive methods like footwear modification and padding to more invasive surgical procedures aimed at restoring function and alleviating pain. The key to successful management lies in a thorough understanding of the toe anatomy, pathology, and individualized treatment strategies to address each patient’s unique needs .
By tailoring interventions to the specific type and severity of the deformity, orthopedic surgeons can improve patient outcomes and quality of life.
Do you have more questions?
Q. What are lesser toe deformities?
A. Lesser toe deformities refer to abnormalities in the second, third, fourth, or fifth toes that affect their position, shape, or function.
Q. What are common types of lesser toe deformities?
A. Common types include hammer toe, claw toe, and mallet toe.
Q. What causes lesser toe deformities?
A. Causes include muscle imbalance, trauma, arthritis, ill-fitting footwear, and underlying neurological conditions.
Q. How does muscle imbalance lead to lesser toe deformities?
A. Muscle imbalance can cause the tendons to pull unevenly on the toes, resulting in abnormal toe positions.
Q. How can trauma cause lesser toe deformities?
A. Trauma such as fractures or dislocations can disrupt normal alignment and function of the toes.
Q. How does arthritis contribute to lesser toe deformities?
A. Arthritis can cause joint inflammation and damage, leading to deformities in the toes.
Q. Can shoes cause lesser toe deformities?
A. Yes, tight or ill-fitting shoes can force the toes into abnormal positions over time.
Q. What are the symptoms of lesser toe deformities?
A. Symptoms include toe pain, swelling, difficulty wearing shoes, corns, calluses, and visible toe abnormalities.
Q. How are lesser toe deformities diagnosed?
A. Diagnosis involves a physical examination and may include X-rays to assess the extent of deformity.
Q. What non-surgical treatments are available for lesser toe deformities?
A. Non-surgical treatments include changing footwear, using orthotics, toe exercises, and padding for corns and calluses.
Q. When is surgery considered for lesser toe deformities?
A. Surgery is considered when non-surgical treatments fail to relieve symptoms or the deformity is severe.
Q. What surgical options are available for lesser toe deformities?
A. Surgical options may include tendon releases, tendon transfers, joint fusion, or bone resection.
Q. How long is the recovery after surgery for lesser toe deformities?
A. Recovery can vary but typically involves several weeks to months, including rest, limited weight-bearing, and physical therapy.
Q. Can lesser toe deformities recur after treatment?
A. Yes, recurrence is possible, especially if underlying causes like improper footwear or systemic conditions are not addressed.
Q. How can I prevent lesser toe deformities?
A. Prevention strategies include wearing properly fitting shoes, avoiding high heels, and performing toe strengthening exercises.
Dr. Mo Athar
