Malpositions of the small toes: Information & specialists

Leading Medicine Guide Editors
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Leading Medicine Guide Editors

Deformities of the little toes are deformities that occur on the little toes, i.e. not on the big toe. They are rarely isolated forefoot deformities. In most cases, these deformities are part of a more complex deformity of the forefoot, usually involving the big toe. Nevertheless, small toe deformities must be considered as a separate entity in the therapeutic concept.

Here you will find further information as well as selected specialists and centers for the malformation of small toes.

ICD codes for this diseases: M20.6

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Article overview

Definitions of small toe deformities

Deformities of the small toe often consist of deformities of several toe joints. The definition of the various small toe deformities is usually based on the deformity close to the trunk of the body:

  • In the case of claw toe, there is always a (sub)luxation in the metatarsophalangeal joint directed towards the back of the foot. A luxation is a dislocation. A subluxation is an incomplete, i.e. partial dislocation. The claw toe is usually accompanied by a flexion deformity in the middle joint and the tip of the toe has lost contact with the ground.
  • In a claw toe, the flexion deformity is found in the middle joint. The toe tip may still be in contact with the ground. Sometimes there are other accompanying toe deformities.
  • A hammer toe is defined as an isolated flexion deformity in the end joint. The tip of the toe remains in contact with the ground.
  • There are also other small toe deformities, such as mallet toe, curly toe and Taylor's bunion.

Intact, mobile little toes are necessary for balancing the foot and they have an important dynamic function in pushing off the foot. Malalignment of the little toes can therefore have a lasting effect on the function and stability of the foot.

What are the causes of malaligned small toes?

Malalignment of the little toes can be caused by increasing tension in the long flexor tendons of the little toes. Responsible for this are

  • often external factors, such as shoes that are too tight or accidents,
  • less frequently physical factors, such as overlong small toes (so-called Greek foot shape) or
  • neurological diseases.

In most cases, small toe deformities occur alongside other foot deformities, such as hallux valgus. Malpositions of the small toes are also often found in cases of hollow foot deformities.

Klauenzehe
Illustration of a claw toe as an example of a small toe deformity © rob3000 | AdobeStock

What are the symptoms of small toe deformities?

If unsuitable shoes are the cause of a misalignment, calluses form over the middle joint of the toe. Calluses appear under the metatarsophalangeal joint in the event of impaired (pathological) load transfer when walking.

Those affected are often unable to touch the ground with the tip of the toe. Sometimes there are also growth disorders of the toenail.

Over time, pain occurs, even on neighboring toes that are not affected. Because of the pain, those affected sooner or later go to the doctor.

How are small toe deformities diagnosed?

The doctor examines the joints for the externally visible symptoms and deformities mentioned above. He will also assess the stability of the joints and their remaining mobility.

An X-ray examination of the foot in a standing position then confirms the diagnosis.

Under certain circumstances, additional examinations such as a foot pressure measurement may be necessary. Foot pressure measurement is often used in preparation for revision surgery. Revision surgery refers to procedures that correct an initial procedure that was not sufficiently successful.

Magnetic resonance imaging(MRI) does not play a significant role in diagnostic considerations either. It is only used to rule out other diseases. This is necessary if the symptoms are not clear enough to make a reliable diagnosis.

What is the treatment for small toe deformities?

In principle, conservative (non-surgical) and surgical measures are possible to correct malaligned toes.

However,conservative procedures can only correct a malpositioned toe at a growing age. In adults, only a surgical procedure can correct a misalignment of the toes.

Conservative measures may be used in adults to prevent a worsening of the condition. Although commercially available aids ("toe correctors") suggest a correction without surgery, they do not promise success.

Conservative therapy for malpositioned small toes

Useful conservative measures include adequate shoe fitting to adapt the shoe to the deformity. A sufficiently large toe box with soft upper leather should be ensured.

Support insoles for the shoes are also a common measure. They should support the metatarsal bones behind their "heads". Soft foam bedding is helpful for the toe pads.

Many sufferers also find small inter-toe pads useful.

Surgical treatment of small toe deformities

The choice of surgical procedure depends on

  • whether the toe joints are stable or unstable and
  • whether the flexion deformity that has occurred is flexible or contracted.

In the case of a flexible flexion deformity in the middle joint, flexor tendon transfer is a possible surgical procedure. The prerequisite is that the base joint is stable. This is referred to as the Girdlestone-Taylor technique.

The excessive flexor tendon tone is redirected to the extensor side of the toe. This results in an extension in the metatarsophalangeal and medial joint. The result is secured with a tape bandage for 3 weeks.

If the metatarsophalangeal joint is stable and there is a contracted flexion deformity in the middle joint, a "resection arthroplasty" of the metatarsophalangeal head is possible (Hohmann technique).

This involves shortening the proximal phalanx by around a third so that the middle joint can be brought into extension. The result is secured with a wire for 3 weeks.

In the case of an unstable proximal joint with a (sub)luxation of the proximal phalanx, this malposition must be corrected first. The "displacement osteotomy of the metatarsal head" (Weil technique) can be used for this. The metatarsal head is shortened to such an extent that a stable joint situation can be achieved. The osteotomy is secured with a screw.

What is the follow-up treatment for small toe deformities?

A special bandage shoe is often recommended until healing is complete. A so-called "forefoot relief shoe" is also possible. Depending on the extent of the procedure, you should wear this shoe for a period of 4 to 6 weeks.

Thrombosis prophylaxis is often recommended during this time, i.e. preventative measures against thrombosis. This is particularly necessary if the affected foot is not allowed to bear full weight.

Decongestant measures are also used shortly after the operation, such as

  • elevation,
  • initially ice application,
  • lymphatic drainage if necessary.

Physiotherapy is also carried out. Particular attention is paid to

  • the ability to flex in the metacarpophalangeal joint,
  • the ability to extend in the middle joint and
  • strengthening the so-called intrinsic foot muscles.

These exercises can then be carried out quickly at home.

Prognosis for malpositioned small toes

If the indication is correct and the surgical technique is applied correctly, a significant improvement in the original foot deformity can be expected. As a rule, the accompanying pain will have disappeared by the end of the healing phase.

In individual cases, a final limitation of movement in the metatarsophalangeal and medial joint remains despite the most careful procedure. However, this has no functional significance, or at best only a minor one. It also does not lead to a noticeable or visible impairment of the gait pattern.

Many of these operations can be performed on an outpatient basis. This means that the patient does not have to stay in hospital and can return home on the day of the operation.

However, the healing process can take between 4 and 8 weeks. This depends on the treatment and surgical method.

After this, the patient can gradually resume sporting activities. After 12 weeks (for "stop-and-go sports"), the patient should be fully fit for sport again.

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