Hammer, Claw & Mallet Toe
Author: Chloe Wilson - BSc(Hons) Physiotherapy
Hammer, Claw and Mallet Toe are similar conditions, all caused by deformity of the toe joints. They usually develop slowly from wearing poor fitting shoes, but can also be due to muscle or nerve damage. Muscle imbalance causes the toes to bend into odd positions which can be extremely painful, limiting walking and activity.
There are two joints in the big toe and three joints in the other four:
1) Metatarsophalangeal Joint (MTP): where the toes start (like your knuckles on your hand)
2) Proximal Interphalangeal Joint (PIP): the middle joint
3) Distal Interphalangeal Joint (DIP): the end joint
Muscles and tendons attach onto these bones and control the position and function of the toes. If tightness or weakness develops in the tendons, most commonly extensor digitorum longus (EDL), flexor digitorum longus (FDL) or the intrinsics, the joints are pulled into the wrong position resulting in either Hammer, Claw or Mallet toe.
Hammer and Mallet Toe are caused by a problem in one joint whereas in Claw Toe, all three joints are affected.
They become more common with aging and affect approximately 10-15% of the population. Women are five times more likely to suffer from hammer, claw or mallet toe than men. They may also lead to other problems such as corns or calluses and long term stiffness in the toes.
Here we will look at the differences in the three conditions, what causes them, common symptoms of each and what the best options are to treat them and prevent them from coming back.
What Are They?
1) Hammer Toe
Hammertoe is caused when the middle joint (PIP) bends down towards the floor (flexion). To compensate, the joints above and below (MTP, DIP) bend up (hyperextend). The result is that the middle part of the toe lifts up.
Hammertoe is the most common deformity of the lesser toes (i.e. not the big toe). It tends to only affect one toe, most commonly the second.
2) Mallet Toe
Mallet toe occurs when the joint at the end (DIP) flexes on a permanent basis. This prevents the toe from being able to straighten and causes the tip of the toe to point downwards.
Mallet toe most commonly occurs in the second toe.
3) Claw Toe
Claw Toe occurs when the final two joints (DIP, PIP) flex to curl the toe downwards. To compensate, the first joint (MTP) hyper-extends so the toe bends up where it meets the foot.
Claw Toe often affects the four outer toes at the same time.
Common Causes
Claw, hammer and mallet toe are most commonly caused by wearing high heels or ill-fitting shoes that are too tight e.g. narrow toebox. If shoes like this are worn for long periods, the foot is held in a slightly bent position and gradually over time, the muscles tighten and shorten.
If this continues for long enough, then the muscles become so tight that even when shoes are removed, the toe is still held in the bent position.
Another common cause is Morton’s Toe, where the second toe is longer than the big toe. In this case, the second toe is commonly squashed into a shoe into an unnaturally bent position.
Other rarer causes include:
1) Poor Blood Supply e.g. peripheral vascular disease
2) Foot Biomechanics e.g. bunions or flat feet
3) Injury e.g. fracture
4) Neural Problem e.g. nerve damage, brain damage or spinal cord injury
5) Joint Disease e.g. rheumatoid arthritis
6) Peripheral Neuropathy: Damage to the nerves in the foot e.g. from Diabetes
7) Genetics: these conditions can be hereditary
Common Symptoms
The most obvious symptom of hammer, claw or mallet toe is the abnormal toe position. This is usually combined with:
1) Pain: the abnormal foot position leads to excessive friction on the toe as it rubs against any footwear which can be extremely painful
2) Corns & Calluses: repeated friction can result in the formation of a foot corn or callus on top of the toes
3) Stiffness: the joints become increasingly stiff. In the early stages, the toes can usually be straightened out passively using your hands, but if allowed to progress, the stiffness may be permanent
Treatment Options
In the early stages, the deformities from mallet toe, claw toe and hammertoe can be corrected. But if treatment is delayed too long, permanent stiffness can ensue which can only be corrected by surgery. The most effective treatment options are:
1) Exercises
Exercises to strengthen and stretch the muscles can be really helpful. Simple things like trying to pick marbles up with your feet or scrunching up a towel underneath your foot can work well. Visit the foot exercises section to find out more
2) Orthotics
Inserts in your shoes can be used to help relieve pressure on the toes from the deformity
3) Good Fitting Footwear
Shoes with a wide toebox will be more comfortable and will reduce the tension on the muscles and friction on the toes. Avoid high heels as they push your feet forwards to the front of the shoes. This increases the pressure on the toes, forcing them to bend more than usual. Shoes should ideally be half an inch longer than your longest toe
4) Splints/Straps
These can be used to help re-align and stretch your toes and correct the muscle imbalance and tendon shortening. One of the most common types used are toe stretchers such as the yogatoe.
You can find out more about how they work and read user reviews in the Toe Stretchers section
5) Injections
Steroid injections can help to reduce pain and inflammation
6) Surgery
The type of surgery required will depend on how limited the joint movement is. Surgery may be done on the tendons or small fragments of bone may need to be removed.
7) Chiropody
A chiropodist can remove calluses or corns, areas of hard skin that have formed to make the foot more comfortable
What Next?
There are a number of other conditions that can cause problems aside from hammer, claw and mallet toe - visit the toe pain section to find out more.
Alternatively if you want help working out what is wrong and what you can do about it, visit the foot pain diagnosis section.
If none of these are sounding quite like your problem, visit the foot pain diagnosis section for help working out what is wrong and what you can do about it.
Go to Common Causes of Foot Pain or Foot Pain Guide
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