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Mallet toe

A mallet toe occurs when the joint at the end of the toe becomes bent. The four smaller toes of the foot are much like the fingers in the hand. Each has three bones (phalanges) which have joints between them (interphalangeal joints). The toes form a joint with the long bones of the foot (metatarsals) and it is this area that is often referred to as the ball of the foot.

Normally, these bones and joints are straight. A mallet toe occurs when the toes become bent at the distal (second) interphalangeal joint, making the toe prominent. This can affect any of the three central toes. In some cases, a bursa (rather like a deep blister) is formed over the joint and this can become inflamed (bursitis). With time, hard skin (callous) or corns (condensed areas of callous) can form over the joints or at the tip of the toe.

What causes mallet toes?

There are many different causes but commonly it is due to shoes or the way in which the foot works (functions) during walking. If the foot is too mobile and / or the tendons that control toe movement are over active, this causes increased pull on the toes which may result in deformity.

In some instances trauma (either direct injury or overuse from walking or sport) can predispose to mallet toes. Patients who have other conditions such as diabetes, rheumatoid arthritis and neuromuscular conditions are more likely to develop hammertoes.

Are women more likely to get the problem?

It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity.

Will it get worse?

At the start of the deformity, it is generally mobile which means that the toe can be straightened. However, with time, the joint become fixed or rigid.

What are the common symptoms?

• Deformity / prominence of toe
• Pain
• Redness around the joints
• Swelling around the joints
• Corn / Callous
• Difficulty in shoes
• Difficulty in walking
• Stiffness in the joints of the toe

How is it recognised?

Clinical examination is generally straightforward, allowing diagnosis.

What can I do to reduce the pain?

There are several things that you can do to try and relieve your symptoms:

• Wear good fitting shoes with a deep toe box
• Avoid high heels
• Use a toe prop to straighten the toe if it is still mobile
• Wear a protective pad over the toe
• See a podiatrist

What will a podiatrist do?

If simple measures do not reduce your symptoms, there are other options:

• Advise appropriate shoes
• Provide a splint or protection
• Advise on surgery

Will this cure the problem?

If the deformity is mobile, then this treatment may help prevent progression although there have been no scientific studies to analyse the benefit. If the deformity is fixed, then these treatments will not cure the problem but may reduce the symptoms.

What will happen if I leave this alone?

Generally, the deformity becomes worse with time and slowly becomes fixed (stiff). This can cause discomfort in shoes.

How can I cure the deformity?

The only effective way of correcting the deformity is to have an operation.

How does the operation correct the deformity?

This is generally a straightforward procedure and correction can be achieved by:

• Digital arthroplasty
• Digital arthrodesis
• Removal of the intermediate phalanx

A digital arthroplasty is usually sufficient to straighten the toe. This involves removing half of the joint to allow it to become free and therefore corrected. In some instances, if the bone in the middle of the toe is very small, it is easier to remove the whole bone.

A digital arthrodesis involves removal of the whole joint which, following a period of time with a wire/pin protruding from the end of the toe, leaves the toe rigid at the joint. This is generally not necessary.

I have heard it is very painful.

The nature of surgery means that there will be pain and swelling, usually worse the night after surgery. However, with modern anaesthetic techniques and pain killers, this can be well controlled. The level of pain experienced varies greatly from patient to patient with some experiencing no significant discomfort. This procedure rarely causes significant discomfort.

Will I have to have a general anaesthetic (be asleep)?

Not if you did not want one. Many of these procedures are performed perfectly safely under local anaesthetic (you are awake). Some patients worry that they may feel pain during the operation but it would not be possible to perform the operation if this were the case.

Will I have to stay in hospital?

No. As long as you were medically fit and have adequate home support, many patients are able to have this type of operation performed as day surgery and go home.

Will I have to have a plaster cast?

Plaster casts are not required for this type of surgery.

Are there a lot of complications?

There are risks and complicationswith all operations and these should be discussed in detail with your specialist. However, with most foot surgery it is important to remember that you may be left with some pain and stiffness and the deformity may reoccur in the future. This is why it is not advisable to have surgery if the deformity is not painful and does not limit your walking. A thorough examination of your foot and general health is important so that these complications can be minimised.

Although every effort is made to reduce complications, these can occur. In addition to the general complications that can occur with foot surgery, there are some specific risks with toe surgery:

• Persistent swelling which may be permanent
• Recurrence of deformity / corn
• Regrowth of removed bone
• Residual pain
• Stiffness or flail (floppy) toe
• You may get discomfort in other parts of your foot during the recovery period. This generally settles.
• There is always a possibility that the deformity may return in later life.

When will I be able to walk again and wear shoes?

In the majority of cases, you will able to walk with the aid of crutches within 2-4 days but you will remain somewhat limited for the first 2 weeks.

Some patients are able to return to wider shoes within two weeks with 60% of patients in shoes at 6 weeks and 90% in 8 weeks. This period is longer for arthrodesis as shoes cannot be worn until the wire/pin has been removed (generally 3-6 weeks).

Swelling generally starts to reduce at 6-8 weeks and the foot will be beginning to feel more normal at 3 months although the healing process continues for 1year.

When will I be able to drive again?

When you feel able to perform an emergency stop. This is generally between 4-8 weeks post operatively but you should always check with your insurance company first.

When will I be able to return to work?

If you are able to get a lift and have a job that is not active and you can elevate your foot, you may be able to return after 1-2 weeks. Generally, patients return to work between 4-8 weeks depending on the type of job, activity levels and response to surgery.

When will I be able to return to sport?

Although the healing process continues for up to 1 year, you should be able to return to impact type activity at around 2-3 months. This will depend on the type of operation you have and how you respond to surgery.