mallet toe is a sub category of
hammer toe. The
term mallet toe comes
from the way the toe hits or hammers on the floor with each step. Mallet toes
differ from hammer toes in the location of the primary deformity. The
primary deformity seen in a hammer toe is found at the PIPJ (proximal
interphalangeal joint) which is the first or more proximal of the two joints of
the toe. A mallet toe, on the other hand, is a similar deformity but is found in
the DIPJ (distal interphalangeal joint). Mallet toes can be present in any
one of the toes or all of the toes simultaneously.
In many instances, patients will have a story regarding how the acquired
their hammer toes. Some describe ill fitting shoes as a child while others
blame high heels or some trendy shoe craze. While these stories may seem
credible, they typically have little to do with the onset of hammer toes.
Hammer toes are an acquired deformity that are inherited from your parents.
For more information on the development of hammer toes, please see the
biomechanics tab below.
Treatment Of Mallet Toes
Treatment of hammer toes ranges from simple shoe modifications to
sophisticated surgical repair. Logic dictates that our initial attempts at
treating hammer toes would include softer and wider shoes. Shoes such as
Crocs, clogs or Birkenstocks offer a wide toe box that in many instances may be enough
of a change to allow pain free walking.
Hammer toe pads are often used to control the
motion of the toe to hold it or bind it in place so that it doesn't rub on the
shoe. Many variations of pads are available for use. The right pad
really depends upon the individual toe location and problem.
Surgical treatment of hammer toes varies from simple releases of the
tendon (bottom of the toe) to complex tendon transfers and bone fusions. The
most commonly used hammer toe procedure is that which was described by Post in
1895. This procedure is referred to today as the Post arthroplasty or Post
(follow this link to view images of a hammer toe surgery).
The Post procedure involves resecting (removing) the knuckle of the toe at the
level of the proximal interphalangeal joint (PIPJ), or in the case of a mallet
toe, the DIPJ. The
Post procedure may be performed in conjunction with a tendon release on the top
(extensor surface) of the foot. The combination of these two procedures
results in a toe that will lay flatter avoiding direct pressure from the
shoe. The Post Procedure may be performed under local or general
Alternatively, some cases of flexible mallet toes will respond to a release
of the flexor tendon on the bottom of the DIPJ. This procedure releases
the tight tendon allowing increased range of motion of the DIPJ.
Extensor tendon - tendon on the top of the toe that dorsiflexes or
pulls up the toe.
Flexor tendon - tendon on the bottom of the toe the plantarflexes
or pulls down the toe.
Interphalangeal joint - joint found between the phalanges.
Phalanges - plural form of phalanx.
Phalanx - on of the bones of the toe.
different types of hammer toes are described by the location of deformity of the
toe. Mallet toes affect the distal interphalangeal joint. The distal
phalangeal joint is the joint located between the middle and distal phalanges.
The extensor digitorum longus tendon and flexor digitorum longus tendons anchor
to the base of the distal phalanx, respectively.
Normal biomechanical function of the toes requires that the toes are stable and
balanced. To create stability in the toes, it's important that the force
generated by the flexor tendon (bottom of the foot) and extensor tendon (top of the foot)
is balanced and symmetrical in applied force. In the case of a mallet toe,
the flexor tendon exerts greater force than the extensor tendon and creates an
imbalance of force at the distal interphalangeal joint. This imbalance of
force results in a contracture of the interphalangeal joint.
There are two biomechanical conditions that we use to describe an
imbalance between the extensor and flexor tendons of the toes. These two conditions are called extensor substitution
and flexor stabilization. Extensor substitution and flexor stabilization
are events that occur in response to an imbalance in the foot. The
imbalance may be due to equinus (a tight calf muscle), pronation (flatfoot) or a
host of other mechanical problems of the foot and leg. As a result, the
tendons that typically control the function of the toes change in their primary
function to help other tendons. Hence the term 'substitution' since these
tendons are substituting their normal function for a new function.
Over the course of our
lives we walk many thousands of miles. If these biomechanical imbalances
are duplicated with each step, eventually we'll see permanent change. In
the case of extensor substitution or flexor stabilization, the long term result
that we see as a sequella of this repetitive biomechanical dysfunction is called
a hammer toe.
The symptoms of a mallet toe can vary. The most common
complaint is a build up of callus at the tip or terminal aspect of the toe.
The callus can become quite painful and in extreme cases actually ulcerate.
An open ulceration of the tip of the toe may lead to infection of the terminal
phalanx called osteomyelitis.
Benign soft tissue tumor
Malignant soft tissue tumor
Products Recommended for Mallet Toe:
This article was written by Jeffrey A. Oster, DPM and last updated 2/8/13. No additional information is available for this topic.
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