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Lesser toe deformities

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What you're feeling¶

Lesser toe deformities change the way your toes sit and move. One or more of your smaller toes may curl down, sit over or under a neighbouring toe, or press against your shoe. The skin over the bony bump can thicken and harden, and that rubbing can leave the area inflamed and sore. In some cases the skin breaks down into an ulcer.

The pain is usually felt in the ball of the foot or on top of a bent toe. It tends to flare when your toes are squeezed into tight or narrow shoes, because the shoe presses on the bone and rubs the soft tissue around it. Roomier footwear takes that pressure off and often settles things down. Foot and ankle pain like this reduces how much you move around, and it can wear on your mood as well as your body.

Daily tasks that load the front of the foot become harder. Walking to the shops, standing while you cook, climbing stairs, or getting through a shift on your feet can all stir the pain up. You may find yourself changing how you walk to keep weight off the sore toes.

Some people with these toe problems also have changes higher up the foot, where the arch is unusually high or the heel sits out of line. If that is part of your picture, it can affect how your whole foot takes your weight.

If you have rheumatoid arthritis, the front of your foot may be affected as well, with toes drifting out of shape alongside changes in your big toe.

What's actually happening¶

Your toes are held straight by a balance between two sets of muscles. One set runs along the top of the foot and pulls the toes up. The other set runs along the sole and pulls them down. When that balance slips, the joints in a toe stop working together. The toe bends down at one joint while bending up at another, which is what creates the curled shapes you can see and feel.

The trouble often starts with a small pad of tissue on the underside of the toe, where it meets the ball of the foot. Think of it as a gasket that seals and steadies the joint. When that gasket wears out or tears, the toe loses its anchor. The tendon on top then wins the tug of war, the toe rides up at its base, and the middle joints buckle downward. As the toe curls, it presses the end of the long foot bone down into the sole. The fat pad that normally cushions that spot gets pushed forward out of place, so you are left standing on bone with less padding. That is why the ball of your foot gets sore, and why hard skin and ulcers can form there.

Shoes play their part too. Tight or narrow footwear squeezes the toes and keeps up the rubbing that inflames the skin over the bump. Some people are born with a foot shape that leans this way, and conditions that affect the nerves or muscles can set it off as well. A high arch, for example, comes from a muscle imbalance in a growing foot, and it changes how your whole foot takes your weight.

If your big toe is drifting sideways as well, the same story applies. The tissues holding it straight gradually give way, the toe turns and slides toward the smaller toes, and the smaller toes can then buckle under the crowding.

What we can do about it¶

Dr Kieran Hirpara, an orthopaedic foot and ankle surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your visit we take a history, examine your foot, and arrange imaging where it is needed. Weight-bearing X-rays are the usual starting point, taken while you stand, and they can include close-up views of the toes. An MRI scan may be used when we need a clearer picture of the soft tissues around the joint.

For most toe deformities we begin with non-operative care. The mainstay is changing your footwear: shoes with a high, roomy toe box take pressure off the curled toe. Foam or silicone gel toe sleeves and crest pads can cushion the sore spots. Padding under the ball of the foot, including metatarsal pad inserts, can spread load away from the painful area. For a bunionette, the bump on the outside of your little toe, we may also shave down the hardened callus. If you have a flat foot as well, an insole or a custom orthotic can help. Physiotherapy and these simple measures cannot straighten the toe itself, but they can settle the symptoms. We usually ask you to give them a fair trial before thinking about surgery.

Steroid injections, sometimes called cortisone, have a very limited place here. For claw toe in particular they can weaken the ligaments that hold the toe steady, and the deformity may then worsen. We use them sparingly, if at all.

Surgery comes into the picture when non-operative care has not given you enough relief, or when the toe has stiffened into a fixed position. The operation is tailored to your toe and to which joints are affected. It may involve straightening the toe by releasing tight soft tissues, removing a small piece of bone from a bent joint, or shortening a long foot bone to rebalance the front of the foot. Tendons can be rerouted or lengthened to restore the pull balance that keeps the toe flat. The damaged pad at the base of the toe can be repaired. Where a joint is badly worn, it may be fused so the toe sits straight and stable. Temporary wire fixation is often used to hold everything in place while it heals, and newer permanent implants are an alternative in some cases. We will talk through which approach fits your foot, and decide together.

What to expect¶

With roomier shoes, padding, and other simple measures, the soreness in the ball of your foot and over a curled toe often settles. Those measures cannot straighten a toe that has already changed shape. If the toe has stiffened into a fixed position, it will usually stay that way without surgery.

If surgery is the right path for you, the aim is a straighter, more comfortable toe and a front of foot that takes your weight more evenly. Recovery is gradual. You will need time for the toe to heal and settle before it feels like part of your foot again. Some approaches are designed to let you move the toe early, which lowers the chance of the toe becoming stiff. Others involve more of the foot and take longer to settle.

Every operation carries some risk. A rare but immediate one after toe surgery is that the blood supply to a toe is reduced. This is seen more often in people who smoke or who are having a toe corrected a second time. Your surgeon will talk you through the risks that apply to your operation.

The outlook depends on your foot and the operation chosen. Some procedures have a track record of few complications, while others, particularly ones that combine several steps in the smaller toes, tend to come with more complications, worse results, and a longer recovery than simpler versions of the same surgery. Your surgeon will weigh up which approach gives your toe the best chance of a good result and a smooth recovery.

When to see someone¶

See your GP if a sore spot over a curled toe or on the ball of your foot is not settling after a few weeks in roomier shoes, or if hard skin there is breaking down into an ulcer. Ask for a specialist review if pain is stopping you walking, working, or sleeping, or if your toes are curling so far that they no longer sit flat in a shoe. Also mention any change in the shape of your foot higher up, such as a very high arch or a heel that sits out of line, because that can affect the whole foot and may need attention as well.

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