Hammertoes, mallet toes and claw toes

What is a hammertoe?

The lesser toes each have three bones joined by two small joints, and they connect to the forefoot at the metatarsophalangeal (MTP) joint. When the muscles and tendons that bend and straighten the toe are out of balance, the toe gets pulled into a bent posture. The pattern of bending gives the deformity its name:

• Hammertoe: the middle joint of the toe (the proximal interphalangeal, or PIP, joint) is bent.
• Mallet toe: the joint nearest the tip (the distal interphalangeal, or DIP, joint) is bent.
• Claw toe: the joint at the base of the toe is bent upward while the two joints beyond it are bent downward.^[2]

Because the toes help you balance and push off, a deformity can change how pressure is spread across the foot. That may lead to calluses, pain and difficulty finding comfortable shoes.^[2]

Swipe sideways to see the whole drawing.

Symptoms

• a toe that is bent and looks like a hammer or a claw
• pain when you move the toe or wear shoes
• corns or calluses on the top of the bent joint or at the tip of the toe
• swelling, redness or burning
• difficulty straightening the toe
• in severe cases, an open sore where the toe rubs^[1,4]

What causes it?

Hammertoes come from muscle and tendon imbalance. Shoes that squeeze the toes into a bent position, such as narrow or high-heeled shoes, are a common trigger. Other contributors include injury, inherited foot shape, inflammatory arthritis, and nerve or metabolic conditions such as diabetic neuropathy.^[3,1] Lesser-toe deformities often go along with a bunion or with problems at the MTP joint at the base of the toe, and correcting one may involve the others.^[3] A torn plantar plate under the toe joint is one such problem; see plantar plate tears.

How it’s evaluated

The examination is the most important step. The key question is whether the joint is flexible (the toe can be straightened by hand) or rigid (it cannot).^[1] We also check whether the joint at the base of the toe is involved, look at the skin for calluses or sores, and check circulation and sensation. X-rays taken while you stand show the alignment of the toe and neighboring joints. Rigidity, and whether the MTP joint is involved, strongly influence what treatment is recommended.^[2,5]

Non-surgical care

For a flexible hammertoe, non-surgical care is the usual first step:

• Footwear: shoes with a deep, wide toe box, enough length, a low heel, and a cushioned or rocker-type sole. Narrow shoes that press the toes onto the ground should be avoided.^[6]
• Pads and straps: cushions or straps that take pressure off the top of the toe or the tip.^[1]
• Exercises: toe-strengthening exercises such as picking up a towel with the toes.^[1]
• Inserts: in some people, an insert or a small pad just behind the ball of the foot reduces pressure under the toe joint.^[6,7]

Research on these measures is limited, so treatment is individualized and adjusted to how you respond.^[7] They can ease symptoms, but they don’t usually straighten a toe that has already become rigid.

When surgery is considered

Surgery is generally reserved for people whose toe has become rigid, whose pain persists despite non-surgical care, or who have recurrent sores or ulcers.^[1,4,3] Options range from soft-tissue procedures, such as releasing or transferring a tendon, to bone procedures such as removing part of a joint, fusing the joint, or shortening a metatarsal, and often a combination.^[3] A flexible toe may be corrected with a tendon procedure alone, while a rigid toe usually needs the joint itself treated.^[1,2]

Two studies of the most common approaches illustrate how similar the results can be. In a randomized trial, removing the PIP joint and fusing it gave comparable pain and function scores at one year, though fusion gave better alignment of the toe.^[8] For people who have a fusion, a systematic review found that newer internal implants gave higher union rates than wires, without clear differences in pain, satisfaction or complication rates.^[9]

Hammertoe correction is often done together with other forefoot procedures. For the operation itself and recovery, see hammertoe surgery.

When to seek care

Consider an evaluation if a toe becomes rigid, if a corn or callus keeps returning, if shoes no longer fit, or if pain limits walking. If you have diabetes or numb feet, have any bent toe with a callus or sore checked promptly, because pressure on a bent toe can lead to an ulcer. See diabetic foot ulcers and infections.