Hammer Toes

The ‘lesser’ toes (toes 2-5) each contain three bones (phalanges) connected to one another and to the ball of the foot by joint capsules. There are also many muscles, ligaments and tissues that attach to their toes and contribute to both their function (like when you curl your toes downwards or point your toes upwards), as well the healthy movement of the foot as a whole.

When changes to the alignment of the joints in the toes occur, this is known as a toe deformity. While these changes may not necessarily be painful in and of their own, they can be disruptive to a person’s gait through the changes in foot biomechanics, can make it difficult to wear shoes comfortably or even find shoes that fit the forefoot, and can result in corns, calluses or blisters developing on the toes that can cause much pain and discomfort if special care is not taken. The position of the toes and toenails in lesser toe deformities may also lead to trauma to the nails itself, leading to bleeding and bruising beneath the nail, changes to the nail shape and appearance, and make the nail more vulnerable to things like fungal nail infections.

Five types of common lesser toe deformities that our podiatrists see include:

1. Hammer Toes

A hammer toe makes an upside down ‘V’ shape in the toes, presenting when the toe bone closest to the ball of the foot extends upwards, and the middle bone points back downwards, with the last toe maintaining a relatively neutral position. Hammertoes often affect the second toe and can occur alongside bunions.

2. Claw Toes

As the name suggests, claw toes have a claw-like appearance, with the first toe bone closest to the ball of the foot pointing upwards, the middle and end bone twisting downwards without curling in on itself beneath the toe. Claw toes often affect the four lesser toes together.

3. Mallet Toes

Mallet toes have a regular toe appearance at the first and second bones closest to the ball of the foot, with the third bone pointing downwards to resemble a mallet. It often affects the second or third toes, and most often occurs when these toes are longer than the big toe and you wear shoes that are a good size relative to the big toe, but too small for the longer toes.

4. Tailor’s Bunion

A tailor’s bunion is similar in nature to a regular bunion of the big toe, except that it affects the little (fifth) toe at the ball of the foot. It gets the name tailor’s bunion due to its historical higher prevalence among tailors, who traditionally used to sit on the ground with their legs crossed through the day, hence applying more pressure to the fifth toe joint.

We have muscles, tendons and ligaments running across the toes and attaching to the joints and supporting a straight toe position. When certain muscles or tendons disproportionately pull on the toe (which can happen due to various causes), an imbalance occurs and the affected toe joint moves, curling the toe upwards or downwards. While these changes may be flexible at first, over time, the joints can become stiff as the muscles tighten or contract, keeping the deformity fixed in place.

Some deformities in their later stages of life may also involve damage to the bone ends themselves, with problems like tailor’s bunions increasing the likelihood of arthritic joint damage over time.

Lesser toe deformities can be caused by factors including: 

• Ill-fitting shoes (often narrow or high-heeled) that put pressure on the joints and hold them in an altered alignment
• Trauma (injury) to the toes
• Nerve damage
• Problems with the big toe like a bunion
• Instability at the joints at the ball of the foot
• Having a longer second or third toe

Having inflammatory arthritis, synovitis, diabetes or musculoskeletal disorders are also implicated in the development of lesser toe deformities.

If you’ve just noticed changes to the position of the joints in your feet, the first thing to review is your footwear as this plays a large role in toe deformity development for many people, especially if your shoes feel tight, have a narrow forefoot, or are high-heeled. Knowing that these shoes are likely contributing to the problem, the best thing you can do is switch to shoes that have a spacious toe box, do not exceed a heel height of 40mm, and do not feel tight, even with thick socks for the cooler months. The earlier you can make these footwear changes, the better. 

If your joints still have good flexibility, you can try exercises to support the strength and flexibility of the toes. This includes gently straightening the toes to bring them into a natural position and holding for several seconds, feeling a long, slow and gentle pull. You can also try towel curls, where you use your toes to crumple a towel that is placed flat beneath your feet, and use your feet to pick up marbles on the floor and drop them into a cup.

If your joints are tender, red or swollen, you can apply ice to the area for 15 minutes at a time, taking a break between icing sessions. Be careful not to apply the ice directly to the skin, instead wrap it in a tea towel or other protective layer. Alternatively you can place your foot in an ice bath for the same time, doing so a few times per day. Using non-steroidal anti-inflammatories (NSAIDs) can also help give you some relief from toe pain.

Managing lesser toe deformities starts with a comprehensive assessment to assess the position, integrity, flexibility and strength of the toes and the joints and muscles. From here, we’ll discuss the likely causes of your toe deformities and put together an evidence-based management plan that supports you in getting the best outcome, whether that is helping slow or stop the progression of the deformity or manage any associated pains and problems.

• Corn and callus care: if the position of your toes is causing painful corns or calluses, we can help you manage your pain and help you walk more comfortably by debriding the calluses and removing any corns
• Toe props and padding: toe props and padding can help to hold the toes in a more comfortable position and reduce the incidence of rubbing and friction both against the neighbouring toes and against the shoes and the ground. This can help relieve pain and improve your comfort
• New footwear recommendations: it can be hard to know which shoes are the best for your feet - and your foot type and arch characteristics play an important role in determining this. We assess your foot posture and give you personalised recommendations for footwear that will put your foot health first, slow the progression of any existing toe deformities, and help minimise the incidence of toe pain and problems related to the toe deformities
• Custom foot orthotics: foot orthotics are custom devices that replace the inner liner of your shoe. In this case, we can design them to help control any muscle and tendon imbalances or instabilities that contribute to the deformities. This will help to alleviate your pain and slow the progression of the deformities, while giving your foot the best support and control. For some deformities like claw toes, orthotics can also be used to offload the bones to relieve pain and improve comfort.

While most lesser toe deformities don’t require surgery, if your toes are fixed in place and are causing you considerable pain or discomfort, we may discuss whether a referral to an orthopaedic surgeon is right for you so you can discuss your surgical options.