Mallet toe is a type of lesser toe deformity.

Before describing the deformity, you may wish to read about the normal anatomy of the lesser toes here.

In a mallet toe the normal anatomy is distorted.

There is flexion at the DIP, with normal PIP and MTP joints.

Mallet toe deformity at the DIP joint

In the early stages of the condition the toe may still remain flexible and the deformity correctible on passive manipulation of the toe. As the condition progresses the deformity becomes fixed.

Mallet deformity of 2nd and 3rd toes

Mallet toe deformity is usually idiopathic which means we do not really understand why it occurs. The following may be associated with the condition:

• Trauma
• Congenital abnormalities
• Inappropriate shoe wear
• Previous surgery to PIP joint
• Neuromuscular conditions
• High arched feet (Pes cavus) 

Patients with a mallet toe deformity usually present with pain, either from a callosity under the tip of the toe or from pressure on the nail.

Examination will reveal whether the deformity is flexible or fixed. The presence of any callosity or ulcer will be noted.

A patient with a painful longstanding fixed mallet toe

Radiographs are a useful first line investigation to rule out any other problems in the forefoot.

Mallet toe deformity of the 2nd toe

Mallet toe deformity is a condition that can get worse over time. Once the deformity is fixed normal loads are not spread across the toe joints. Point pressure can develop at the tip of the toe. The nail can also deform. A painful callosity often develops and in severe cases the skin can break down and form an ulcer.

Clinical photograph of a patient who has had previous toe surgery and has now developed a painful ulcer over a mallet toe deformity

Non-operative management aims at relieving pain and limiting deformity progression. It is likely to be most effective in the early stages of the condition.

It should always be the first line of treatment. Options include:

Toe sleeves 

Made of silicon can be worn over the toe to protect from direct pressure and rubbing against footwear.

Taping/strapping

Position the toe in neutral alignment using cross over taping or toe straps. Provide stability to the joint and alleviate symptoms.   Custom mallet toe splints are available.

Insoles & orthotics

Soft insoles and padding under the toe.

Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort.

Footwear

Wearing a shoe with a wide and deep toe box. Avoid wearing high heels. A shoe with a stiff toe box that prevents bending and loading of the toes.

Physiotherapy

Stretching tight calf muscles will help reduce the forces going across the forefoot.

Stretching exercises that straighten the toe.

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. Often a combination of procedures is performed. Because the deformity results from a muscle imbalance, tendon lengthening may be needed in order to achieve a correction and minimise the risk of recurrence. When planning surgery it is important to note whether the deformity is fixed or flexible.

The most common procedures that may be used in combination with others include:

For flexible mallet toe deformity

• Flexor digitorum longus (FDL) tenotomy
• DIP joint plantar capsule release
• The toe may be held in position temporarily using a 1.1 Kirschner wire (K-wire) 

For fixed mallet toe deformity

• DIP joint fusion – Straightening the toe without pinning is not enough in a fixed deformity. There is a high risk of recurrence of the bend at the DIP joint. To minimise the risk of recurrence, some of the bone in the joint is removed and the middle and distal phalanges fused in a straightened position. It is not unusual for this joint not to fully heal with bone, but even a fibrous union (scar tissue) in a straight position will be effective in the majority of patients. The bones are held in place by a temporary metal wire (K-wire) which is removed at roughly 4-6 weeks.

Chronic fixed deformity

• In the presence of severe infection or uncorrectable deformity resulting in significant symptoms, rarely an amputation may be considered

Minimally Invasive Surgery (MIS)

• Some of the above procedures will be attempted in the first instance using a minimally invasive surgical technique

In summary the aim of surgery is to correct the deformity, alleviate pain and return a patient to full function.

Patient with hallux interphalangeus and 2nd mallet toe corrected with an Akin osteotomy and DIP joint fusion held with temporary K wire

It should be borne in mind that complications can result from a condition with or without surgery.

Potential complications of non-operative treatment include:

• Worsening pain
• Increasing deformity
• Formation of ulcers on the pulp of the toe
• Formation of ulcers across the top (dorsum) of the toe as it rubs against the shoe
• Infection of ulcers

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

• Risks and complications of anaesthesia
• Bleeding
• Infection (superficial and deep)
• Blood clots
• In the case of an MIS procedure it may be necessary to proceed to open surgery if during the operation it is felt that a better outcome will be achieved using an open technique
• Failure to fully correct deformity (particularly if longstanding deformity)
• Need for further surgery
• Complex regional pain syndrome

Potential specific complications of operative treatment of mallet toes include:

• Painful non union of the DIP joint
• Recurrence of the deformity
  • Failure to fully correct the mallet deformity
  • Recurrence of the deformity over time
• Malunion
  • It is not uncommon for the toe to heal in a position that may not be perfectly straight
  • Minor degrees of deformity will be mostly a cosmetic concern, which is why almost all orthopaedic foot and ankle surgeons discourage patients from having toe surgery if the underlying issue is cosmetic!
  • In the unlikely case that there is a severe malunion further surgery may be required
• Wound healing problems (particularly when correcting a chronic deformity the soft tissue can become contracted)
• Compromise to the blood supply (particularly when correcting a chronic deformity the blood vessels can become contracted)
  • If the blood supply to the tip of the toe is lost the tissue will die and it may be necessary to amputate part, or all of the toe
  • This is a very small risk
• Nerve injury to the toes causing numbness

Note – these complications are not exhaustive and are meant as a guide

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.

Immediate post operative period

Almost all surgical procedures for mallet toe deformity correction will be undertaken as a day case.

You will have a bandage applied similar to this during the operation.

Post operative bandage of the foot

Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.

Post operative stiff soled shoe

For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.

High elevation of the foot and ankle

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.

Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped.

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.

Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 weeks before any driving is advisable.

Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.

Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.

Six weeks post operatively

You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 weeks to heal.

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.

You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.

Three months post operatively

Final clinical examination. Discharge if satisfactory.

When can I drive?

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.

When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.

What should the final outcome be?

Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.