Mallet Toes

A mallet toe refers to a toe bent at the end, resembling the shape of a mallet.

Each small toe has three bones called phalanges and two joints called interphalangeal joints. The joint closer to the foot is called the proximal interphalangeal joint, while the one closer to the tip of the toe is called the distal interphalangeal joint.

Mallet toes is a deformity of the small toes in which the distal interphalangeal joint is bent, causing pain and discomfort. This condition is less common than hammer toes in which the proximal interphalangeal joint is bent.

It mostly involves the second toe and is more commonly seen in females (probably because of footwear choice). Initially the joint is flexible but with time, it becomes stiff making the toe remain bent permanently.

Causes:

  • Wearing shoes that are too tight or high heels with narrow toes sections, is considered a major factor in the development of mallet toes.
  • Tight shoes press against the toes. When toes remain cramped in a bent position for too long, the muscles that stay in a contracted position become tight. Due to the tight muscles, it becomes difficult to straighten the toes, even when there is no pressure from the shoes.
  • A toe injury, either direct or due to overuse, can also lead to the development of mallet toes
  • Conditions that damage the muscle or nerve control such as cerebral palsy, stroke, diabetes or other neuromuscular diseases.
  • Diseases affecting the joint such as osteoarthritis or rheumatoid arthritis.It may also be a result of an inherited foot structure.

Symptoms:

The toe bends at the outer end in the shape of a mallet.

The end joint becomes stiffer with time

The bent toe rubs against the inside of the shoe, leading to pain and swelling

A corn (localized hardening of the skin) may develop in the skin above the bent joint as a result of friction from the shoe.

If the friction continues, a bursa may form under the corn. A bursa is a fluid-filled sac under the skin; it is a protective response of the body against constant friction to prevent damage to the joint underneath.

Diagnosis:

The condition is clearly diagnosed from its appearance and the patient’s history. An X-ray may be required to evaluate the condition of the bone.

Treatment:

Conservative treatment:

In the early stages when the toe is still flexible, the problem can be solved with conservative measures such as relieving pain and pressure by:

wearing comfortable shoes with broader toe sections to allow sufficient room for the toes

avoiding high heels and narrow toes completely

using gel toe caps or cushions to protect against friction from the shoe

Gel and gel-lined toecaps relieve pressure and friction to prevent corns

Supporting and aligning the toe by:

Using toe straighteners and splints

Practising toe exercises to stretch and strengthen the toe muscles and increase their flexibility. Ultrasonic massage also helps to improve the joint condition.

Surgery:

However, when the toe has become rigid, or when the discomfort remains even after conservative treatment, surgical correction may be required.

Flexor tenotomy:

When a little flexibility still remains in the toe, it is possible to straighten the toe by incising the stiff flexor tendons – a procedure called flexor tenotomy. The tendons are band-like extensions of the muscles that attach them to bones. Releasing a tendon relaxes the tight muscle and straightens the toe in most cases.

To straighten a totally rigid toe, it may be required to remove part of the joint to allow for free movement, or remove the joint totally and fuse the two phalanges together. The toe will become straight but the end of the toe would no longer bend.

On the other hand, the distal phalanx (the toe bone at the tip) may need to be removed partially or completely.

It is always better to seek treatment in the early stages to avoid surgical intervention.