Hammer, Claw, and Mallet Toes

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What are hammer, claw, and mallet toes?

Hammer, claw, and mallet toes are toes that do not have the right shape. They may look odd or may hurt, or both. The muscles that control your toes get out of balance and cause the toe to bend into an odd position at one or more joints. These toe problems almost always happen in the four smaller toes, not the big toe.

If you notice that your toe looks odd or hurts, talk to your doctor. You may be able to fix your toe with home treatment. If you do not treat your toe right away, you are more likely to need surgery.

These toe problems develop over years and are common in adults. Women have more of these problems than men because of the types of shoes they may wear, such as high heels.

What causes hammer, claw, and mallet toes?

Tight shoes are the most common cause of these toe problems. Wearing tight shoes can cause the toe muscles to get out of balance. Two muscles work together to straighten and bend the toes. If a shoe forces a toe to stay in a bent position for too long, the muscles tighten and the tendons shorten (contract). This makes it harder to straighten the toe. Over time, the toe muscles cannot straighten the toe, even if you are not wearing shoes.

Less common causes include:

• Problems in foot structure at birth. This may run in families.
• Joint diseases, such as rheumatoid arthritis.
• Brain, spinal cord, or nerve injury (especially in the case of claw toe). Examples include stroke, cerebral palsy, and degenerative disc disease.
• Not using your toe. Having to stay in bed for a long period of time may cause muscles to shorten (contractures). This may lead to toe problems.
• Poor blood flow to your feet (peripheral arterial disease).
• Having little or no "feeling" in your feet (peripheral neuropathy). This is common in people with diabetes.
• Injury, such as breaking a toe.

What are the symptoms?

Pain and a toe that looks odd are symptoms of hammer, claw, and mallet toes. The toe may rub against your footwear, and you may have trouble finding shoes that fit.

• A hammer toe is a toe that bends down toward the floor at the middle toe joint. It usually happens in the second toe. This causes the middle toe joint to rise up. Hammer toes often occur with bunions.
• Claw toe often happens in the four smaller toes at the same time. The toes bend up at the joints where the toes and the foot meet. They bend down at both the middle joints and at the joints nearest the tip of the toes. This causes the toes to curl down toward the floor.
• A mallet toe often happens in the second toe, but it may happen in the other toes as well. The toe bends down at the joint closest to the tip of the toe.

See pictures of hammer, claw, and mallet toes.

In more severe cases, these toe problems may affect your balance and make it hard to walk. You may get calluses or corns where a bent toe presses against your shoe.

How are hammer, claw, and mallet toes diagnosed?

Your doctor will diagnose your toe problem by looking at your toes and asking you questions about your symptoms. People rarely need tests. Your doctor may suggest an X-ray to look at the bone structure, especially if you are thinking about having surgery.

How are they treated?

You can treat hammer, claw, and mallet toes at home by wearing footwear with lots of room for your toes, using pads and supports in the shoe, and doing toe exercises. Doing these things will give the toe room to straighten, cushion the toe and hold it straight, and make the toe muscles stronger and more flexible. You can use over-the-counter medicine to treat pain.

If your pain is too great or you cannot easily do daily activities, then surgery is possible. But there is not much research on surgeries for these toe problems. Talk to your doctor about the types of surgeries and how much they may help you.

Surgery may not help how your foot looks, and your toe problem may also come back after surgery. This is more likely if you continue to wear the types of shoes that cause toe problems.

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	Hammer, claw, or mallet toe: Should I have surgery?
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	Foot problems: Finding the right shoes

The symptoms of hammer, claw, and mallet toes are deformity of the toe, pain, and difficulty fitting into shoes. These toe joint deformities are usually easy to see by looking at the toes and comparing them to pictures of these deformities.

See pictures of hammer, claw, and mallet toes.

Hammer and mallet toes usually occur in your longest toe. This is usually your second toe, next to the big toe. Claw toe usually affects the lesser toes (those other than the big toe) at the same time. Mallet and claw toes may cause deformed toenails.

Hammer, claw, and mallet toes usually develop slowly, over years.

Pain, sores, calluses, or corns may occur at the:

• Upper part of the toe, where the raised joint rubs against your footwear.
• Tip of the toe. This almost always occurs with mallet or claw toes, and often occurs with hammer toe.
• Ball of the foot, which is the area of the bottom of the foot, between the arch and the toes.

Sores can become infected and lead to cellulitis or osteomyelitis, especially if you have diabetes or peripheral arterial disease.

Your doctor will ask you questions about your symptoms and past health and do a physical exam to diagnose hammer, claw, and mallet toes. People rarely need tests, but your doctor may use an X-ray to assess the bone structure, especially if you are considering surgery.

Your doctor will ask questions about:

• Your symptoms, including when the problems started, what activities or shoes make them worse, and what other parts of the foot are painful. This includes asking about the shoes you wear at work and how much time you spend standing or walking every day.
• The type of footwear you wear each day.
• Any previous foot problems or treatment for foot problems you have had.
• Other medical conditions that may be related. Such conditions include:
  • Joint diseases (such as rheumatoid arthritis).
  • Brain, spinal cord, or nerve injury (such as diabetic neuropathy).
  • Shortened muscles (contractures).
  • Poor circulation of blood to the feet (peripheral arterial disease).

During the physical exam, your doctor will look at your foot:

• While you stand, to diagnose the problem.
• While you sit, to check whether the joint deformity is fixed or flexible.

If you are thinking about having surgery to correct your toe joint problem, you may need:

• An X-ray, to help determine what type of surgery (if any) would be most helpful.
• Blood flow testing (vascular testing), which may include Doppler ultrasound, if your condition suggests that blood flow to and from your foot is poor.
• Nerve conduction testing, if your condition seems to involve problems with nerve function in your foot. If this is the case, you may need a doctor who specializes in the brain, spinal cord, or nerves (neurologist).

You can often use nonsurgical methods to treat hammer, claw, and mallet toes. These include wearing roomy footwear, using pads and supports in your shoe, and doing toe exercises. These measures provide room for the toe to straighten, cushion the toe and hold it in a straightened position, and stretch the toes so that they are more flexible. You can take medicine to treat pain. Surgery is an option if nonsurgical treatment does not control pain, your toe joint deformity limits your activity, or you cannot move the toe joint.

The goals of treatment are to relieve pain so that your hammer, claw, or mallet toe does not limit your activities and to prevent the problem from getting worse. Even if your toes remain bent, your doctor will consider the treatment a success if he or she can relieve or reduce your pain enough to make you comfortable.

Initial and ongoing treatment

It is usually best to use nonsurgical treatment for hammer, claw, or mallet toes first. Treatment options for both fixed and flexible toe joint deformities include:

• Changing footwear. Shoes should be roomy, with wide and deep toe boxes (the area that surrounds the toes), low heels, and good arch supports. This provides room for your toe to straighten and prevents your toe deformity from rubbing or pressing against the shoe. One option is to wear custom (orthotic) shoes.

  Foot problems: Finding the right shoes

• Wearing moleskin, pads, arch supports, or other orthotic shoe inserts. These products may cushion the toe or hold the foot and toes in a more comfortable position. They are better for treating a flexible deformity, but they also provide some relief for a fixed deformity. Your health professional can show you how to put pads or inserts in your shoe.
• Taking nonprescription pain relievers. Examples include acetaminophen, such as Tylenol, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin , or naproxen. Check with your health professional before taking these medicines.
• Taking prescription pain relievers, which you may need if you have severe pain.
• Getting a corticosteroid injection, which may reduce pain and inflammation for a period of time. But this does not change the joint structure causing the toe pain and is not commonly used. Your toe joint may be more painful for several days after the injection than it was before the injection.
• Caring for any calluses or corns on your toes or feet. Moleskin and other nonprescription treatments for corns or calluses may help relieve pain and burning. Never cut corns or calluses by yourself, because this can lead to infection. See home treatment for calluses or corns.

Nonsurgical treatment specifically for flexible toe joint deformities includes:

• Taping or splinting hammer toes into place. Wrap tape under the big toe (or the toe next to the hammer toe), then over the hammer toe, and then under the next toe, gently forcing the hammer toe into a normal position. You may use a splint for the same purpose. Wrapping a toe does not straighten the toe permanently.
• Using toe caps or toe slings. These hold toes in a normal position, much like wrapping the toes with tape.
• Doing stretching exercises that help keep the toe joints flexible so that you can bend and straighten them. To do stretching exercises, gently pull on your toes to stretch the bent joints in the other direction, and hold the stretch for several seconds at a time. For example, if a joint bends up, gently stretch it down. Work on just one joint at a time. You should feel a long, slow, gentle pulling. Do this stretching several times in the morning and several times in the evening. To work on strength, try putting a towel flat under your feet and using your toes to crumple it and using your toes to pick up things, such as marbles. Your doctor, nurse, or physical therapist may be able to recommend more exercises.

Treatment if the condition gets worse

If your hammer, claw, or mallet toe gets worse or if nonsurgical treatment fails to reduce pain or discomfort, surgery may be an option. Generally, surgery is used only for severe toe deformities. Surgery may not completely return your toes to their normal positions, and toe joint problems may return after the surgery.

Surgical options may include one or a combination of the following:

• Phalangeal head resection (arthroplasty), in which the surgeon removes part of the toe bone.
• Joint fusion (arthrodesis), in which the surgeon removes part of the joint, letting the toe bones grow together (fuse).
• Cutting supporting tissues or moving tendons in the toe joint. This can relax the tension on the joint and allow the toe to straighten out.

Doctors often use surgery on the bones for fixed toe problems, and they move tendons for flexible toe problems.

Should I have surgery for hammer, claw, or mallet toes?

What To Think About

Doctors generally advise everyone, especially athletes, children, and people who have health problems such as diabetes, to take a conservative, careful approach when considering foot surgery.

If you have surgery for a toe problem, your surgeon may also operate on other toe joints to improve your symptoms.

Whether you have surgery generally depends on:

• The type and degree of your deformity. Claw toe may be more likely to cause pain and limit activities, and your doctor may suggest surgery. Hammer toe or mallet toe may respond better to nonsurgical treatment. Surgery is only used when pain and discomfort disrupt your daily life or other treatments have not worked.
• Whether the toe problem is fixed or flexible. With a flexible deformity, you have more options for treatment. For a severe fixed deformity, surgery may be the only solution when nonsurgical methods fail to control pain.
• Whether you have more than one toe problem. For example, if a bunion is pushing the second toe into a hammer toe position, surgery to correct the bunion can make room for the second toe. At the same time, surgery can correct the hammer toe.

A person typically has foot surgery as an outpatient, so you probably will not have to spend a night away from home. But other factors, such as your overall health, may make a hospital stay necessary.

Recovery from surgery often takes 4 to 8 weeks, although it may take longer. How long it takes depends on the procedure you have done and how many problems your surgeon repairs. You may need follow-up X-rays. You may be able to walk on the affected foot right after surgery, possibly with a special shoe. How soon you can start wearing your own shoes depends on how quickly you recover.

Home treatment is an important part of caring for hammer, claw, and mallet toes.

For fixed or flexible toe joint deformities:

• Change your footwear. Shoes should be roomy, with wide and deep toe boxes (the area that surrounds the toes), low heels, and good arch supports. This provides room for your toe to straighten. One option is to wear custom (orthotic) shoes.

  Foot problems: Finding the right shoes

• Wear moleskin, pads, arch supports, or other orthotic shoe inserts. These products cushion the toe or hold the foot and toes in a more comfortable position. They are better for treating a flexible deformity, but they can also provide some relief for a fixed deformity. Your health professional can show you how to put the pads or inserts in your shoe.
• Care for any calluses or corns that you have on your toes or feet. Moleskin and other nonprescription treatments for corns or calluses may help relieve pain and burning. Never cut corns or calluses, because this can lead to infection. See home treatment for calluses or corns.

Nonsurgical treatment specifically for flexible toe joint deformities includes:

• Taping or splinting hammer toes into place. Wrap tape under the big toe (or the toe next to the hammer toe), then over the hammer toe, and then under the next toe, gently forcing the hammer toe into a normal position. You may use a splint for the same purpose. Wrapping a toe does not straighten the toe permanently.
• Using toe caps or toe slings. These hold toes in a normal position, much like wrapping the toes with tape.
• Doing stretching exercises that help keep the toe joints flexible so that you can bend and straighten them. To do stretching exercises, gently pull on your toes to stretch the bent joints in the other direction, and hold the stretch for several seconds at a time. For example, if a joint bends up, gently stretch it down. Work on just one joint at a time. You should feel a long, slow, gentle pulling. Do this stretching several times in the morning and several times in the evening. To work on strength, try putting a towel flat under your feet and using your toes to crumple it and using your toes to pick up things, such as marbles. Your doctor, nurse, or physical therapist may be able to recommend more exercises.

If your hammer, claw, or mallet toe is severe or very painful, it may be better to stop wearing shoes and wear only sandals that don't press on painful areas. If you can't wear sandals, you can cut holes in your footwear to ease painful rubbing.

If you have nerve injury caused by diabetes, poor circulation, or advanced rheumatoid arthritis, talk to your doctor or nurse about special shoes that both protect your feet and prevent toe problems.

To relieve pain, try:

• Acetaminophen, such as Tylenol, or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin, or naproxen. Check with your health professional before taking these medicines.
• Soaking your toes in warm and then cold water (contrast baths) for temporary relief, 2 or 3 times a day. If a foot or toe is numb, take care when you use warm water.

When to call your doctor

If your pain does not go away or increases after 2 to 3 weeks of home treatment, or if you develop sores on any of your affected toes, contact your doctor.

Organizations

Related Information

• Bunions

Other Works Consulted

• Krug RJ, et al. (2008). Hammer toe. In WR Frontera et al., eds., Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation, 2nd ed., pp. 453–456. Philadelphia: Saunders Elsevier.

• Maguire S (2008). Mallet toe. In WR Frontera et al., eds., Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation, 2nd ed., pp. 457–459. Philadelphia: Saunders Elsevier.

• Mann JA, et al. (2006). Deformities of the lesser toes section of Foot and ankle surgery. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 4th ed., pp. 475–480. New York: McGraw Hill.

• Wang D (2008). Claw toe. In WR Frontera et al., eds., Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation, 2nd ed., pp. 437–440. Philadelphia: Saunders Elsevier.