Mallet Toe & Claw Toe: Deformity Correction | Balance Foot

Mallet toe, hammer toe, and claw toe are three distinct lesser toe deformities that differ in which joint is contracted and the pattern of flexion and extension deformity -- correctly identifying the deformity guides the specific surgical correction. The lesser toe joints: the proximal interphalangeal joint (PIPJ) is between the proximal and middle phalanx; the distal interphalangeal joint (DIPJ) is between the middle and distal phalanx; the metatarsophalangeal joint (MTPJ) connects the metatarsal to the proximal phalanx; Hammer toe: flexion contracture of the PIPJ only; the MTPJ may be neutral or slightly extended; the DIPJ is usually flexible or neutral; the toe buckles at the PIPJ, creating the characteristic hammer shape; the dorsal PIPJ develops a painful corn from rubbing against the shoe; the most common lesser toe deformity; Mallet toe: flexion contracture of the DIPJ only; the PIPJ and MTPJ are neutral; the distal tip of the toe curls downward; a corn develops at the tip of the toe (from walking on the tip) or at the dorsal DIPJ; the nail may be deformed from abnormal pressure; Claw toe: the most severe deformity; hyperextension of the MTPJ combined with flexion contracture of both the PIPJ and DIPJ; the proximal phalanx is dorsally dislocated on the metatarsal head; the plantar fat pad migrates distally under the toe, exposing the metatarsal head; corns develop on the dorsal PIPJ and DIPJ and at the toe tips; severe pain with both dorsal shoe pressure and plantar metatarsal head pressure; associated with intrinsic muscle weakness (claw toe is the foot equivalent of intrinsic-minus hand); frequently associated with peripheral neuropathy and cavus foot (high arch); Flexible vs. rigid: in early deformity, the contracture is flexible -- the toe can be passively straightened; in chronic deformity, the joint capsule and ligaments contract, making the deformity rigid; this distinction determines whether splinting and orthotics can help (flexible) vs. surgical joint release or fusion being required (rigid).

Surgical correction of lesser toe deformities is tailored to the specific joint involved, the severity of contracture (flexible vs. rigid), and whether the MTPJ is dislocated -- the standard procedures are PIPJ arthroplasty (resection arthroplasty) or PIPJ arthrodesis (fusion) for hammer toes, DIPJ arthrodesis for mallet toes, and more complex MTPJ release with tendon transfers for claw toes. Conservative treatment (before surgery): for flexible deformities: a hammertoe splint or toe alignment device passively corrects the deformity and may prevent progression; a metatarsal pad reduces the pressure under the dislocated MTPJ in claw toe; footwear with a deep, wide toe box eliminates shoe pressure on the dorsal corn; gel tube toe sleeves protect the corns from friction; professional callus debridement provides temporary relief; conservative management does not correct structural deformities -- it controls symptoms; Hammer toe surgical correction: PIPJ resection arthroplasty (proximal interphalangeal joint arthroplasty): the head of the proximal phalanx is resected, creating a pseudarthrosis; the resulting mobility allows the toe to straighten without a fixed joint; preferred for patients who want some residual toe flexibility; a K-wire is used to hold the correction for 3-4 weeks; PIPJ arthrodesis (fusion): the joint surfaces of the PIPJ are removed and the joint is fused in a straight position with an implant, K-wire, or intramedullary device; provides the most reliable and permanent straightening; preferred for severe or recurrent deformities; Mallet toe surgical correction: DIPJ arthrodesis: the DIPJ surfaces are resected and fused with a K-wire or implant; the toe tip is straightened; Claw toe surgical correction: MTPJ release: for the hyperextended MTPJ, an extensor tendon lengthening (EHL tenotomy or Z-lengthening) is performed; a plantar plate repair addresses the torn plantar plate that allows the MTPJ dislocation; the PIPJ and DIPJ flexion contractures are corrected with PIPJ arthroplasty or arthrodesis and DIPJ flexor tenotomy; in severe MTPJ dislocation: a shortening metatarsal osteotomy (Weil osteotomy) reduces the length of the metatarsal, allowing the proximal phalanx to reduce back onto the metatarsal head; Recovery: K-wire removal at 3-4 weeks postoperatively; full weightbearing in a surgical shoe from day one; transition to regular shoes at 4-6 weeks; final result assessed at 3-4 months as swelling resolves.