Sometimes it is the seemingly small problems in life that create a lot of trouble.
A wise person once said:
“If you want to forget all your troubles, then put on a pair of shoes that don’t fit!”
Foot Pain: Common Issues and Their Impact
A patient with a painful foot is, statistically, most likely to be suffering from a bunion or from plantar fasciitis. These are very common issues. However, problems affecting the smaller toes can also create a lot of discomfort, as well as difficulty with activities and problems with shoe fitting.
The names that these toe problems are given does nothing to dispel the impression that Orthopaedic surgeons are simple carpenters: hammer toe, mallet toe and claw toe They even sound like items from a tool kit.
All three terms describe subtly different deformities of the lesser four toes. Each has its own unique shape. Each presents with different problems. Each requires different treatment.
The causes behind these toe complaints vary widely and it takes careful assessment and consideration of all the factors to know how to best to try and help.
1. Hammer toe
A hammertoe bends up in the middle, with the first joint of the toe (the proximal interphalangeal joint – PIPJ) flexed. The knuckle joint in the ball of the foot at the root of the toe (metatarsophalangeal joint – MTPJ) is extended. The last joint of the toe near the nail (the distal interphalangeal joint – DIPJ) is extended too.
Hammer toe deformity most frequently affects the second toe and is usually associated with a problem of the neighbouring big toe. Even a mild bunion or a small amount of wear and tear arthritis (hallux rigidus) forces the patient to subconsciously take weight off the big toe when they stand and walk. “Crabbing over” leads to the second toe having to work hard.
The second toe is much smaller than the big toe. In a normal foot the big toe does two thirds of all the work, so if it is not contributing sufficiently then the second toe becomes overloaded. This leads to a series of changes within the second toe that eventually result in hammer toe formation.
The first stage is inflammation of the second toe metatarsophalangeal joint. This may present with pain and swelling in the forefoot. It is frequently misdiagnosed as a Morton’s neuroma. Stretching the joint down or up is uncomfortable. Squeezing the joint top to bottom is tender. There may be swelling and sometimes redness. At this stage the toe is still straight.
If the joint is inflamed for long enough, then the ligaments that hold the toe straight at the MTP joint become stretched. This allows the toe to change shape. Sometimes there is medial or lateral deviation. More commonly the toe starts to lift as the strong ligament beneath the joint (called the plantar plate) becomes stretched and eventually torn. Ironically at this more advanced stage in the development of a hammer toe the initial pain in the ball of the foot gets better. Sadly, because the toe rises and becomes flexed in the middle, a new problem arises – namely that the now flexed PIP joint rubs on shoes.
Treatment
Prevention is better than cure and, if caught at an early stage, strapping, rest and appropriately supportive orthotics will allow the inflammation to resolve. Attention may need to be given to the big toe problem that so frequently accompanies a toe that is threatening to become hammered. Calf stretches for a tight Achilles tendon can be beneficial too.
A relatively mild hammer toe remains flexible at all the joints and if surgery is required this may be achieved with tendon lengthening, tendon transfer or osteotomy to adjust the bones.
Once a hammer toe has become stiff it is often necessary to fuse the proximal interphalangeal joint to ensure that the toe stays straight.
2. Mallet toe.
A mallet toe is defined as one where the last joint (distal interphalangeal joint DIPJ) is flexed. The more proximal joints are not affected. The deformity can be flexible or stiff. It may be associated with a second toe that is longer than its neighbours.
Problems occur because the tip of the toe strikes the ground instead of the pulp of the toe. This leads to callosities and distorted nail growth. The resultant problems can be very painful indeed.
Non-surgical treatments include ensuring that shoes are long enough, as well as skin and nail care.
A flexible toe can be improved surgically with a simple tenotomy that can be performed under local anaesthetic.
If the joint is very stiff, or if the toe is long, then combining a tenotomy with distal interphalangeal joint (DIPJ) fusion helps maintain the corrected posture and simultaneously shortens the toe a little. Minimally invasive keyhole surgery can be used to achieve this under local anaesthetic. Treatment is therefore suitable even for frail patients.
3. Claw toe
If both interphalangeal joints (PIPJ and DIPJ) of the toe are flexed, then the toe has a claw toe deformity. Symptoms include difficulty with shoe fitting, corns on the proximal joint and toe tip pain (as per mallet toe).
Shoes that a deep enough, padding and skin care all help alleviate some of the symptoms. Surgical treatment entails an a la carte approach, with tenotomy, joint fusion and osteotomy all having a part to play.
KEY MESSAGES
- Small toes can bring big problems.
- Diagnosis: Pain in the ball of the foot is only rarely from a Morton’s neuroma Diabetes and inflammatory arthropathy must not be overlooked.
- Treatment: Appropriate shoes and other non-surgical treatments are helpful Surgery is a last resort, but with modern key-hole techniques can even be performed under local anaesthetic.
