A mallet toe is a deformity of the distal interphalangeal joint in the foot, which has abnormal flexion that is either fixed or flexible. It may also be accompanied by symptoms of pain or callosity. For most patients, the longest toe is affected, but it can also occur in the second, third or fourth toe joint.
The global incidence of mallet toe is not known, but it is less common that other foot deformities such as hammertoe, with one case for every nine cases of hammertoe in the Unites States.
In most cases the cause of mallet toe is not known, referred to as idiopathic. There are various factors that have been associated with an increased risk of mallet toe, however, including:
- Ill-fitting footwear
- Proximal interphalangeal (PIP) joint fusion
- Congenital abnormalities
- Neuromuscular disorders
- Pes cavus
All of these potential causes place additional pressure on the tip of the toe or attenuate the extensor tendon in the toe. As a result, calluses or deformity of the nail can also affect the tip of the toe.
Symptoms and Diagnosis
Mallet toe is characterized by the joint at the end of the toe that buckles into an abnormal shape. Patients that present with the deformity often report symptoms of pain and inflammation associated with the callosity or nail deformity. Some asymptomatic patients may present based upon the cosmetic aspect of the toe, although many people do not seek medical attention unless symptoms present.
There are two types of mallet toe. Flexible mallet toes are still developing and the toe joint can be moved, whereas rigid mallet toe involves tightening of the tendon and joint misalignment that hinders movement.
The patient consultation should include a complete medical history, specifying any family history of health condition and other factors that may have caused the deformity, such as trauma, surgery or infection. Other concurrent medical conditions that have an impact on the management of the condition (e.g. diabetes, vascular disease, neuropathy) should also be discussed.
A physical examination of the toe and evaluation of the severity of symptoms should also be undertaken, including observing the overall alignment of the foot. The metatarsophalangeal joint (MTP) and the proximal interphalangeal (PIP) should be assessed, as well as the location of callosities and nail abnormalities.
The first-line management approach for patients mallet toe is non-surgical, due to the increased risks associated with surgery, such as infection and permanent nerve injury.
Initially, wearing shoes with toe boxes that allow more room for the toes and avoiding causative footwear (e.g. high heels) can prevent further pressure on the affected toe. Additionally, a cushioned pad worn over or beneath the toe can also help to reduce pain.
Using a pumice stone to rub the calluses and reduce their size can help to reduce symptoms. Physical therapy can also be used to stretch and strengthen the toe muscles by doing exercises prescribed by a physiotherapist.
Most patients with mallet toe will not require surgical treatment. However, surgery may be indicated when there is particularly severe pain associated with mallet toe. Some patients may also wish to undergo surgery based on cosmetic reasons, although the benefits of surgery should always be weighed up against the risks.
There are some instances when surgical treatment is contraindicated. This includes conditions such as active infection, psychiatric disorders and vascular compromise.
Following surgery, many patients note sensations of pain, numbness, tingling or burning in the foot, which can often be relieved by elevating the foot. Analgesic medication can help to ease the pain post surgery. Patients are encouraged to avoid putting weight on the affected side in the early recovery period. Follow-up X-rays are used to monitor the healing 3-6 weeks after surgery and most patients make a full recovery within 6-12 weeks.