Introduction

Mallet toe is a type of small toe deformity and is characterised as descending bowing at the toe joint. As a result, the toe looks bent rather than flattened. This condition mostly happens in the second toe in which (DIPJ) Distal interphalangeal joint (last joint which is close to the nail) and (FDL) Flexor Digitorum Longus (a tendon which assists in toe twisting) are involved.¹

Common foot conditions and their impact on toes

Lesser toe disfigurements (LTD) are common and can be uncomfortable. These deformations happen progressively and can involve multiple toes. It occurs when there is an imbalance between the strength of the extensor and flexor ligaments of the lesser toes.¹¹

Patients with lesser-toe disfigurements complain of pain, difficulty finding shoes that fit or are comfortable, and feet that look different to normal. The strain on the toes from a shoe might result in painful calluses, nail changes, or even ulceration. Additionally, patients may experience pain in the ball of their foot, known as metatarsalgia.

There are many different types of lesser-toe deformities, such as mallet, claw, hammer, and crossover toes. Some deformities can be corrected and should address the underlying issue, not just the resulting deformity.¹²

Causes of mallet toe

Footwear 

Inappropriate footwear choice is the foremost reason for developing a mallet toe. Narrow and tight-fitting footwear puts more stress on the toes as they don't have enough space to move. Also, high heel sandals cause enhanced pressure towards the toes.²

Genetics and family history

Genetics or family history is also involved in the occurrence of such toe deformity.²

Underlying medical conditions

Some conditions have an adverse effect on foot bones, nerves and joints that can cause mallet toes. Such conditions include diabetes, arthritis, neuromuscular condition, or foot injury.²

Symptoms of mallet toe

The most common symptoms of mallet toes include ^1,2

• Pain and discomfort in the affected toe, especially when walking
• Deformity of the affected toe
• Difficulties wearing some shoes because of pain or deformity
• Corn and calluse formation at pressure points

Types of mallet toe

Flexible mallet toe

In this type, the joints and muscles are still moveable.³

Rigid mallet toe

In this type, the muscles and joints begin to stiffen and ‘freeze’ the toe in its new shape.³

Diagnosis

Mallet toes can be diagnosed by a healthcare professional or podiatrist (foot and ankle specialist).¹ They will:

• Ask you questions about your symptoms and medical history⁴
• Perform a physical examination that will look at your foot and ankle movements, the presence of calluses, and your walking (gait analysis)⁴
• They will potentially order imaging, such as x-rays, to look at the joint health¹

Treatment options

Mallet toe deformity can be treated by the following options:

Non-surgical approaches

Most cases can be treated by:

• Footwear modifications. It is a first choice of strategy which is done by doctors, and patients are motivated to use wide-spaced, soft-sole shoes and instructed to avoid wearing high heel shoes²
• Toe exercises and stretches. Some exercise is helpful to treat such deformity and gives strength to muscles

Padding and splinting. Due to severe pressure towards toes, calluses occur, so removal of thick parts to be done and splinting and different paddings are used to treat to avoid such pressure and corns etc. 

Medications for pain and inflammation

To alleviate pain and inflammation, some analgesics and steroid injections are used so that a patient can easily do their day-to-day work.¹

Surgical interventions

Surgical options are used when non-operative procedures don’t show effectiveness towards the condition.

1. Arthroplasty

Toe joint substitution (toe arthroplasty) is a surgery that replaces the toe joint. The medical procedure can assist with reducing pain and discomfort and reestablishing the capability of a toe.⁵

2. Arthrodesis

It is also known as fusion surgery, which is used to correct toe deformities so that the toe becomes straightened by using metal wire and clasp inside a toe.⁶ This fixes the joint so that it can no longer move and is generally used to reduce pain.

3. Tendon transfer

Moving the ligament such as Flexor Digitorum Longus in such type of toe deformity to a different place on the foot to drive the toe to a straightened position.¹

Preventive measures

There are a number of ways you can prevent mallet toes:

Proper footwear choices

Keep away from shoes that squeeze or group your toes, and use low-impact point footwear to ease the pressure on your toes. Also, have your shoes measured by a professional.

Toe exercises and stretches

Do the stretch exercises of your feet and toes routinely to strengthen the toe muscles, such as towel twists (Put a towel level under your feet and by toe assistance, try to fold it), do marble pickups (try to get marbles with the help of toes and drop them in a cup).⁸

Regular foot check-ups

It is needed to prevent further infection, blisters, recurrence of bending position and wound conditions.⁷

Complications

The following can occur as a result of mallet toes:

Chronic pain and discomfort

In the early stages, you may feel that your toe looks somewhat odd, and maybe you will encounter less pain. However, mallet toes are a dynamic condition; without treatment, symptoms will likely worsen. As symptoms worsen, you might experience an increase in pain, discomfort, and deformity, making it difficult to find footwear that fits.¹⁰

Development of corns, calluses, and blisters

Twisted toes can rub against your shoes, causing blisters, corns, and calluses.^9,10

Impact on overall foot structure and gait

In the most serious cases, you might find it difficult to walk or balance.¹⁰

Lifestyle recommendations

Some changes in daily routine can help to prevent such toe deformity including.

Maintaining a healthy weight

Excessive weight has adverse effects not only on health, but also it has an effect on foot and joints so proper weight management is essential.

Managing underlying medical conditions

With medical conditions such as diabetes or arthritis, there is an increased chance of developing toe deformities, which can further cause nerve and bloody supply issues in your feet and toes. If not properly managed, this can result in ulcers. You should consult a healthcare professional if you notice this.¹

Proper foot care and hygiene

Always take care of your feet by cutting toenails, removing dead or dry skin, and selecting proper shoes with pressure-bearing pads.¹

Summary

There are several types of lesser toe deformities that affect people's day-to-day routines. Due to such deformities, patients experience pain, difficulty in walking and inappropriate posture or unbalancing issues. 

One such deformity is mallet toes, which usually affects the toe next to the big toe. In this condition, the distal joint and FDL tendon are involved and cause the toe to be fixed in a bent position. This can cause pain or difficulty walking. 

It needs a proper and correct diagnosis to differentiate it from other conditions. To treat this condition, patients need to make changes in their lifestyle, such as choosing properly fitting wide-spaced shoes with less or no heel, cutting toenails, and thoroughly cleaning their feet. 

Also, they have to do some exercises to make their toe muscles strong. If there are no significant results shown by making such lifestyle changes, then you may benefit from undergoing a surgical procedure. 

Patients have to take care of their feet and toes even after the successful surgical procedure to avoid the recurrence, possibility of infection and other conditions. Some underlying conditions, such as diabetes and arthritis, exaggerate the effects and make the patient’s condition worsen.