There is a large percentage of the population with toe deformities, especially bunions and claw and/or hammer toes. This explains why they are the main reason for podiatrists to consult podiatrists.
Usually the bunion deformity causes deviation of the first toe over the other toes, which in turn causes the toes to become deformed. At other times, claw toes or bunions may develop independently.
The type of footwear, the structure of the foot, previous traumas or injuries as well as inflammatory diseases can cause the development of these toe deformities.
In order to understand toe deformities it is necessary to explain that with the exception of the big toe which is composed of two bones or phalanges, the rest of the toes or little toes are formed by three phalanges, proximal, middle and distal.
The joints between bones form articulations and finally, the toes move thanks to the extensor and flexor tendons of the toes.
What are claw and/or hammertoes?
Fingers without deformity are in a neutral position, however when they are subjected to continuous pressure or there is an anatomical alteration or neurological deficit, an imbalance between the tendon, ligament and muscle structures is produced, causing a deformity.
Bunion or hallux valgus causes the big toe to deviate towards the second toe causing pressure and deformity in the second toe.
Toe deformities are called claw, hammer or swan neck depending on which joint is affected.
A claw toe occurs when there is dorsal flexion of the phalanx over the metatarsophalangeal joint (metatarsal attachment to the proximal phalanx) and flexion of the proximal and distal interphalangeal joints.
Hammertoe occurs when there is abnormal flexion of the medial interphalangeal joint.
Finally, mallet toe occurs when the toe is in a neutral position, except for the distal interphalangeal joint which is in flexion.
Claw and/or hammer toes
Toe deformities often go unnoticed in the early stages when the deformity is mild and flexible, i.e. the toes fit into the shoe without pain.
These deformities worsen over time, becoming stiff and dislocating. At this stage, claw toes produce deformity pain and metatarsalgia (pain in the distal plantar part of the foot).
The stages of claw and/or hammertoes are defined by the degree of stiffness and deformity they acquire over time:
- Flexible claw and/or hammer toes: there is a deformity of the toe but it is completely corrected when the foot is placed on the ground or manual pressure is applied.
- Semi-rigid claw and/or hammer toe deformity: there is a deformity of the toe but it is not completely corrected when the foot is placed on the ground or manual pressure is applied.
- Rigid claw and/or hammer toes: when the toe presents a severe and rigid deformity that is also painful with normal footwear.
The foot specialist or podiatrist, through a physical examination of the foot, will be able to make an accurate diagnosis of the type of toe deformity the patient has. Normally, in flexible claw toes or in the initial stages, when pressure is applied to the plantar aspect of the foot, the toe is observed to stretch and the deformity disappears.
However, when the deformity does not disappear, we are dealing with rigid claw and/or hammer toes with advanced deformity. In these cases, the only definitive treatment is surgery or minimally invasive foot surgery.
It is important to remember that bunions have a direct impact on toe deformities. For this reason, bunions should be corrected as soon as possible to avoid toe deformities that require more complex and painful surgical treatment.
Why do claw and/or hammertoes occur?
Claw and/or hammertoes are caused by an anatomical alteration or neurological deficit that causes an imbalance in the muscular and tendon structures that cause the deformity of the toe. This deformity worsens over time and is usually related to several factors:
Bunions produce an instability and deformity of the big toe that indirectly and over time affects the other toes causing claw and/or hammer toe deformity.
Type of shoe. High heeled shoes with narrow toes cause the toes to crowd together in a very tight space.
Previous trauma and injury. Previous injuries or surgeries of the foot that have caused alterations or injuries to the joints of the foot can produce claw and/or hammer toe deformities.
Inherited disorders of the muscular structures of the toes can cause instability and subsequent deformity of the toes.
There are also several risk factors for the development of claw and/or hammer toes:
Age. The risk of developing claw and/or hammertoes increases with age.
Gender. Women are more likely to develop claw and/or hammertoes than men.
Toe length. The Greek foot with a second toe that is longer than the first toe is more at risk of developing claw and/or hammer toe.
Inflammatory diseases or even diabetes are more likely to develop foot joint deformities.
What is the relationship between bunions and claw and/or hammer toes?
A bunionette or hallux valgus can initially be diagnosed with the naked eye as a deformity or protrusion on the medial side of the foot, more or less at the level of the big toe. The deviation of the big toe caused by bunions must be treated as soon as possible, otherwise the toe will not only become subluxated but will also cause deformities in the other toes.
The deviation of the big toe produces excessive and continuous pressure on the second toe causing an imbalance of the intrinsic and extrinsic musculature of the toe which eventually becomes claw and/or hammer toe deformity.
The best treatment for claw toes is preventative, which is why when a patient has a bunionette or hallux valgus deformity, they should see a foot specialist or podiatrist to correct this deformity as soon as possible to resolve the bunions and reduce the likelihood of claw and/or hammer toe deformity.
However, when the patient already has a claw and/or hammer toe deformity, he or she should see a foot specialist or podiatrist for an assessment. In the initial stages, custom-made orthopaedic insoles and silicone orthoses may be sufficient, and in more severe cases, minimally invasive surgery for claw toe correction may be the best option.
Bunion surgery to prevent claw and/or hammer toes
Bunions can be mild, moderate or severe. In the latter, the bony protrusion is usually accompanied by a deviation of the big toe that often affects the second toe, deforming it.
In these cases, it is very important to perform surgery to correct the bunions and thus avoid the deformity of claw and/or hammertoes.
Minimally invasive or percutaneous bunionette surgery may be an option to correct bunions definitively and prevent the development of claw and/or hammertoes.
Depending on the degree of bunion deformity, two minimally invasive techniques can be used to correct bunions
Surgery for mild bunions or hallux valgus without fracture (without osteotomy):
Minimally invasive or percutaneous surgery allows simple resection of the bunion bony deformity, which involves a 7-day postoperative period with hardly any discomfort and full mobility.
It is performed under local anaesthesia and does not require any type of screw or pin. This surgery must be performed by foot specialists with extensive experience in these techniques and with special apparatus and instrumentation.
Surgery for bunions or moderate-severe hallux valgus with fracture (with osteotomy):
In more advanced cases of bunions where there is significant deviation of the big toe which may or may not affect the second toe, resection of the bony protrusion of the bunion and correction of the corresponding angles must be performed. In cases where there is also claw and/or hammertoe deformity, these should be corrected in the same surgical procedure.
All these procedures can be performed with a minimally invasive or percutaneous technique without the need for screws or pins, both for the correction of bunions and for claw and/or hammertoes.
The postoperative period for this surgery is usually 40 days, during which the patient is walking from the first day with the aid of a special post-surgical shoe for these techniques.
The specialist or podiatrist must be consulted to carry out a complete study of the foot, which usually requires a physical examination of the foot and lower limbs, digital X-rays, a computerised study of the footprint and, finally, a vascular ultrasound scan of the lower limbs.
The specialist must explain clearly and precisely the best surgical option depending not only on the degree of deformity but also on the patient’s age and associated diseases. Finally, once the patient has understood the procedure, a decision about surgery can be made.
Corrective surgery for claw and/or hammer toes
There are various surgical techniques for the correction of claw and/or hammertoes depending on the degree of deformity.
Minimally invasive or percutaneous surgery is usually the best option as long as it is performed by highly experienced surgeons. In certain cases, open techniques may be necessary to obtain better results. In general, it can be performed:
Arthroplasty: consists of removing the part of the bone that causes the deformity, maintaining a certain degree of mobility and achieving a shortening of the finger.
Arthrodesis: consists of correcting the deviation of the toe by fixing the joint in the neutral position.
Digital plastic surgery or “Cinderella feet”: on some occasions it may be necessary to shorten a toe by a few millimetres to obtain a proportional foot that fits in the usual footwear.
These procedures can also be combined with other techniques to achieve better alignment of the toes and eliminate the metatarsalgia that patients with claw and/or hammer toes often experience.
It is important to see a foot specialist or podiatrist for a complete study in order to be able to offer a personalised treatment for each patient.
Postoperative period for bunionette and claw and/or hammer toe surgery.
Recovery from bunion and claw and/or hammer toe surgery with minimally invasive or percutaneous surgery is 40 days when a fracture (osteotomy) is performed, and 7-14 days when no fracture is required.
During the entire post-operative period, patients are walking with the aid of a special shoe, with hardly any discomfort and minimal swelling, thanks to these techniques that cause minimal tissue damage and therefore allow for a faster and more comfortable recovery than with other techniques.
Patients will be given an information sheet on the post-operative care of bunion and claw and/or hammer toe surgery as well as all the information necessary for a quick and comfortable recovery.
If you or someone you know has bunions or toe deformities, do not wait any longer as time will only aggravate the problem.
It is advisable to see a foot specialist or podiatrist for an initial assessment and, if necessary, corrective surgery for bunions and claw toes using minimally invasive or percutaneous techniques.
Remember that the feet are the fundamental pillar of our body, as they support your weight throughout your life.
(Bauer et al., 2010)
BAUER, T., BIAU, D., LORTAT-JACOB, A. and HARDY, P., 2010. Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy. Orthopaedics & Traumatology: surgery & research, 96(4), pp. 407-416.
(Bauer et al., 2009)
BAUER, T., DE LAVIGNE, C., BIAU, D., DE PRADO, M., ISHAM, S. and LAFFENÉTRE, O., 2009. Percutaneous hallux valgus surgery: a prospective multicenter study of 189 cases. Orthopedic Clinics of North America, 40(4), pp. 505-514.
(Brigan et al., 2009)
BROGAN, K., LINDISFARNE, E., AKEHURST, H., FAROOK, U., SHRIER, W. and PALMER, S., 2016. Minimally Invasive and Open Distal Chevron Osteotomy for Mild to Moderate Hallux Valgus. Foot & ankle international, 37(11), pp. 1197-1204.