Mallet toe

• 735.4 Other hammer toe (acquired)

• M20.40 Other hammer toe(s) (acquired), unspecified foot

• 4E: Impaired joint mobility, motor function, muscle performance, and ROM associated with localized inflammation

Description

• Distal joint of the toe is bent into a claw like position
• Usually due to trauma from impact on tip of the toe
• Flexor muscles, fascia, tendons shorten
• Flexion of the distal interphalangeal joint (DIP)
• Most commonly affects the 2nd toe; can also be 3rd to 5th
• May alter mechanics during the push-off phase of gait

Essentials of Diagnosis

• Diagnosis is usually made by clinical examination or x-ray
• Can be an independent diagnosis and not associated with a disease process

General Considerations

• Swelling
• Inflammation around the joint
• Altered joint position

Demographics

• Infants
  • Congenital
• Children
  • Results from wearing shoes that are too small
• Adults
  • Poor footwear: too small or narrow, toe comes to a point, high heels
• Dancers
  • Trauma from impact on tip of the toe

Signs and Symptoms

• Pain in metatarsal with walking
• Corn on top of the toe above the DIP joint
• Decreased extension or dorsiflexion of the toe
• Joint redness and pain
• Callus formation under the metatarsal head

Functional Implications

• Pain with standing
• Pain with ambulation at the toe
• Inability to wear stiff shoes
• Need to wear larger shoes to accommodate bunion, large toe box
• Alteration of gait pattern (such as no toe off, forefoot abduction, decreased arch height) and mechanical issues of the forefoot
• Difficulty finding shoes

Possible Contributing Causes

• Muscle imbalance
• Trauma
• Pes planus (flat foot)
• Improper show wear
• Commonly seen in conjunction of bunions
• Joint arthritis/injury
• Muscle atrophy
• Nerve damage
• Friedrich’s ataxia
• Osteoarthritis
• Rheumatoid arthritis
• Stroke
• Charcot-Marie-Tooth disease
• Diabetes

Differential Diagnosis

• Hammer toe: different in that it is flexion of the PIP (generally extension/depression of the MTP and DF of PIP)
• Hallux valgus
• Gout
• Osteochondrotic lesion of the first metatarsal head
• Sesamoiditis; turf toe
• Osteochondritis dissecans
• Metatarsalgia
• Metatarsal stress fracture

• Imaging
  • X-ray

• Bone spur, location and size

• Medication
  • Anti-inflammatory
• Surgery to straighten out the toe and lengthen ligaments/tendons.

• For Imaging, x-ray
• For corticosteroid injection
• For surgical consult to straighten out the toe, which may involve cutting or lengthening tendons and ligaments and possible fusion of the joint

• Antalgic gait secondary to pain at the toe with push-off
• Inability to ambulate distances of one mile secondary to pain

• Rest, keep weight off feet to reduce inflammation
• Orthotics with ray cut out
• Taping techniques
• Address swelling and pain
  • Ice
• Address pain
  • Ice
  • Massage
  • Joint mobilization
  ...