Lesser Toe Deformity: Hammertoe, Mallet Toe & Claw Toe | DPM

Lesser toe deformities — hammertoe, mallet toe, and claw toe — are among the most common foot conditions seen in podiatric practice, representing a spectrum of abnormal flexion contractures at different joint levels of toes 2-5. The distinction between these three deformities is anatomically important: hammertoe involves the proximal interphalangeal joint (PIP); mallet toe involves the distal interphalangeal joint (DIP); and claw toe involves both the MTP joint (extension) and both interphalangeal joints (flexion). The further critical clinical distinction is between flexible deformity (passively correctable to neutral) and rigid deformity (fixed contracture not correctable without surgery) — this determines whether pads and splints can provide long-term relief or whether surgery is necessary.

Lesser Toe Deformity Classification: Hammertoe vs. Mallet Toe vs. Claw Toe

Deformity	Joint Involvement	Position	Common Cause	Callus/Corn Location
Hammertoe	Proximal interphalangeal (PIP) joint flexion; MTP may be in neutral or slight extension; DIP variable	PIP flexed; DIP may extend or flex; toe has “hammer” profile when viewed laterally	Extrinsic muscle imbalance (long flexors overpower short intrinsics); hereditary; tight toe box shoes; cavus foot; neuromuscular disease	Dorsal PIP (corn from shoe pressure); distal toe tip (from DIP extension contact with ground)
Mallet toe	Distal interphalangeal (DIP) joint flexion only; PIP and MTP relatively normal	DIP flexed; toe tip directed plantarward; “mallet” appearance at tip	Flexor digitorum longus overactivity; tight long flexors; poorly fitting shoes; trauma to DIP	Distal toe tip corn (tip ground contact); subungual keratosis (nail bed pressure)
Claw toe	MTP joint hyperextension; PIP flexion; DIP flexion — all three joints involved	MTP extended; PIP and DIP flexed; toe describes claw shape; proximal phalanx dorsally subluxed on metatarsal	Intrinsic muscle weakness/paralysis (neuropathy, cavus, RA, Charcot Marie Tooth); MTP joint instability; plantar plate insufficiency	Dorsal PIP corn; dorsal DIP corn; distal toe tip; plantar metatarsal head (from MTP extension shifting weight to head)
Crossover deformity	MTP instability with medial or lateral deviation of toe at MTP level; often with claw component	2nd toe crosses over or under hallux; medial deviation from lateral collateral ligament laxity; plantar plate tear common	Plantar plate insufficiency at 2nd MTP; hallux valgus pushing 2nd toe medially; long 2nd toe; inflammatory arthritis	Dorsal pressure sores from crossed toe; plantar 2nd metatarsal head callus

Lesser Toe Deformity: Treatment by Flexibility and Severity

Stage	Flexibility	Conservative Treatment	Surgical Treatment
Stage 1 — Flexible deformity	Passively correctable to neutral with no resistance; muscle imbalance only, no fixed contracture	Toe splinting or sleeve to hold correct position; toe crest pad under proximal phalanx lifts toe; shoe modification (extra depth, wider toe box); stretching of long flexors	Flexor tendon transfer (flexor-to-extensor transfer) rebalances forces; preserves joint motion; best for young patients with flexible deformity
Stage 2 — Partially flexible	Reducible with pressure but springs back; mild soft tissue contracture; no joint articular change	Silicone toe splint; custom orthotic to offload metatarsal head; accommodative shoe; conservative measures slow progression but do not correct deformity	PIP arthroplasty (resection of PIP joint head and condyles) + Kirschner wire fixation for 4-6 weeks; DIP flexor tenotomy for mallet toe
Stage 3 — Rigid deformity	Non-reducible; fixed contracture of joint capsule and collateral ligaments; articular changes present	Padding and shoe modification for symptom management only; no correction possible without surgery; accommodative custom orthotics	PIP fusion (Girdlestone-Taylor procedure): resection of PIP joint and fusion in neutral; most reliable for rigid hammertoe; K-wire for 6 weeks; implant arthroplasty as alternative
Stage 4 — MTP dislocation (severe)	MTP joint dislocated or subluxed; claw toe with plantar plate disruption; non-reducible	Extra-depth shoe; metatarsal pad; surgical consult needed for adequate treatment	MTP joint capsular release + flexor tenotomy + plantar plate repair + Weil metatarsal osteotomy to shorten metatarsal; complex reconstruction; K-wire 4-6 weeks

At Balance Foot & Ankle in Howell and Bloomfield Hills, lesser toe deformities are evaluated with the passivity test — the podiatrist assesses whether each deformed joint can be manually reduced to neutral, which determines whether conservative splinting and padding will provide correction or whether surgical arthroplasty or fusion is the only path to correction. Call (810) 206-1402.