Mallet Toe

A 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 flexor 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 procedure (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 anesthesia.

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.

The 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. 

Abscess
Blister
Benign soft tissue tumor
Glomus tumor
Porokeratoma
Eccrine poroma
Infection
Malignant soft tissue tumor
Malignant melanoma
Kaposi's Sarcoma
Psoriasis
Ulcer
Verrucae
Wart

• Callus

• Hammer Toes

• Claw Toe

• Toe Nail Injuries

• Lister Corn

This article was written by Jeffrey A. Oster, DPM and last updated 2/8/13. No additional information is available for this topic.