toes

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toes

lesser toes (LT) and hallux (great toe) see Table 1
  • absent toe congenital/traumatic/surgical toe loss, with resultant pathomechanical forefoot shape changes and overall foot dysfunction

  • claw toe mobile/fixed LT sagittal plane deformity, characterized by proximal phalanx dorsiflexion at metatarsophalangeal joint, intermediate phalanx plantarflexion at proximal interphalangeal joint, distal phalanx plantarflexion at distal interphalangeal joint, with weight-bearing apex and nail-free margin (weight-bearing dorsal nail plate in severe cases)

  • curly toe mobile, transverse-plane LT deformity, characterized by abduction of proximal phalanx, neutral intermediate phalanx and adduction of distal phalanx (in relation to intermediate phalanx)

  • flexed toe fixed congenital sagittal-plane LT deformity, characterized by plantarflexion of proximal and distal interphalangeal joints, contracture of plantar soft tissues of toe, and weight-bearing dorsal nail plate and eponychium

  • hammer toe symptomatic/non-symptomatic, fixed/mobile sagittal-plane LT deformity characterized by dorsiflexion of proximal phalanx at metatarsophalangeal joint, plantarflexion of intermediate phalanx relative to proximal phalanx and (variably) neutral, dorsiflexion or plantarflexion of distal phalanx relative to intermediate phalanx; associated metatarsal head may become plantarflexed and load-bearing due to pressure from dorsal orientation of base of proximal phalanx; associated with hallux abductovalgus, local trauma, pathology of associated metatarsal head (e.g. Freiberg's disease), inflammatory joint disease (e.g. rheumatoid arthritis) or congenital malformation; typical associated hyperkeratotic lesions include apical and dorsal interphalangeal joint lesions (callosity/corn formation), nail pathologies (onychauxis, onychophosis, subungual corn/callosity), plantar hyperkeratotic lesions of associated metatarsophalangeal joints, metatarsalgia secondary to subluxation of associated metatarsophalangeal joint

  • lesser toes; LTs all toes other than hallux

  • mallet toe fixed (e.g. joint pathology)/flexible (e.g. soft-tissue contracture) sagittal plane LT deformity characterized by neutral proximal phalanx at metatarsophalangeal joint, neutral position of intermediate phalanx at proximal interphalangeal joint, marked plantarflexion of distal phalanx at distal interphalangeal joint, weight-bearing at apex, free nail margin and sometimes dorsal nail plate; leads to apical corn/callosity, subungual corn formation and local nail hypertrophy

  • retracted toe mobile/fixed sagittal-plane LT deformity, characterized by dorsiflexion of proximal phalanx at metatarsophalangeal joint, plantarflexion/neutral intermediate phalanx at proximal interphalangeal joint, plantarflexion/neutral distal phalanx at distal interphalangeal joint; neither apex nor pulp is weight-bearing

  • sausage toe; dactylitis acute sero-negative inflammatory arthropathy affecting joints of one toe in patients with psoriasis; characterized by generalized soft-tissue inflammation (swelling, heat, redness and pain) in affected toe, characteristic erosions and/or new bone formation around affected joints, 'pencil in cup' metatarsophalangeal joint and interphalangeal joint formation and phalangeal resorption (see Table 2)

  • tennis toe chronic traumatic toenail injury leading to subungual haematoma and/or nail plate hypertrophy, caused by rapid pivotal movements of the toe against shoe box; also seen in netball players and joggers

  • trigger toe mobile/fixed sagittal-plane first-ray deformity characterized by plantarflexion of first metatarsal head (i.e. plantarflexed metatarsal), dorsiflexion of hallux proximal phalanx relative to support surface, and plantarflexion of distal phalanx relative to orientation of proximal phalanx; medial apex of hallux and free margin may become weight-bearing

  • turf toe episode of hallux limitus/rigidus caused by direct trauma/stubbing hallux; characterized by local inflammation, first metatarsophalangeal joint pain especially on movement, hallux plantarflexion at first metatarsophalangeal joint and protective spasm of flexor hallucis brevis muscle; treated by RICE(P) (see Table 3), non-steroidal anti-inflammatory drugs, rest (using soft splintage and/or fan strapping; see Table 4) and orthoses as necessary

  • valgus toe rotational transverse LT deformity characterized by abduction and external rotation (pronation) of proximal phalanx, neutral intermediate phalanx and abduction and external rotation (pronation) of distal phalanx in relation to intermediate phalanx; medial pulp and nail fold area are weight-bearing

  • varus toe rotational, transverse LT deformity characterized by abduction and supination of proximal phalanx, neutral intermediate phalanx, adduction and supination of distal in relation to intermediate phalanx, with weight-bearing of lateral nail fold and lateral area of nail plate; toe is prone to Durlacher's corn at lateral sulcus (secondary to pressure and friction of transverse-plane movement occurring at toe off)

Table 1: Features of lesser-toe deformities
DeformityClinical features
Hammer toeSagittal-plane deformity
• Hyperextension at MTPJ
• Hyperflexion at PIPJ
• Hyperextension/neutral/flexion at DIPJ
Mallet toeSagittal-plane deformity
• Neutral MTPJ
• Neutral PIPJ
• Hyperflexion at DIPJ
• Apical skin weight-bearing
Clawed toeSagittal-plane deformity
• Hyperextension at MTPJ
• Hyperflexion at PIPJ
• Hyperflexion at DIPJ
• Apical skin weight-bearing
Hyperflexed toeSagittal-plane deformity
• Hyperextension at MTPJ
• Hyperflexion at PIPJ
• Hyperflexion at DIPJ
• Dorsum of nail and terminal segment bearing
Retracted toeSagittal-plane deformity
• Hyperextension at MTPJ
• Hyperflexion at PIPJ
• Hyperflexion at DIPJ
• Apical skin non-weight-bearing
Curly toeTransverse-plane deformity
• Adduction/neutral or abduction at MTPJ
• Adduction at PIPJ
• Adduction at DIPJ
Varus toe (adductovarus toe)Transverse and frontal-plane deformity
• Abduction ± inversion of digit at MTPJ, or neutral MTPJ
• Adduction or neutral at PIPJ
• Adduction at DIPJ
• ± Frontal plane (inversion) rotation of terminal segment of digit
Valgus toe (abductovalgus toe)Transverse and frontal-plane deformity
• Adduction ± eversion of digit at MTPJ, or neutral MTPJ
• Abduction or neutral at PIPJ
• Abduction at DIPJ
• ± Frontal plane (eversion) rotation of terminal segment of digit
Overriding toeSagittal and transverse-plane deformity
• Adduction and extension at MTPJ
• Neutral PIPJ
• Neutral DIPJ
Underriding toeSagittal and transverse-plane deformity
• Abduction and flexion at MTPJ
• Neutral PIPJ
• Neutral DIPJ

The main types of lesser-toe deformity (LTD) are listed in this table; some presenting LTDs may show the features of more than one type. LTDs may be fixed (due to joint pathology) or flexible (due to soft-tissue contracture). LTDs may characterize neurological and skeletomuscular diseases, hallux abductovalgus, hallux limitus/rigidus, compensation for excess pronation at the subtalar and midtarsal joint, and pathomechanical anomalies in the foot and lower limb. Hyperkeratotic skin lesions develop in areas of exposed digital or interdigital skin that are subject to excess pressure and/or friction, as the result of the toe deformity and shoe trauma.

MTPJ, metatarsophalangeal joint; PIPJ, proximal interphalangeal joint; DIPJ, distal interphalangeal joint.

Table 2: Common features of the range of types of sero-negative inflammatory arthritis
FeatureComment
Leukocyte antigen type90% of patients with sero-negative arthritis test positive for human leukocyte antigen (HLA) B27
Skeletal involvementAxial skeleton/spinal involvement; with back pain (common presenting first symptom)
EnthesopathyInflammation at insertions of ligaments/tendons (posterior calcaneum, plantar calcaneum, base of fifth metatarsal, forefoot)
Soft-tissue swellingsLocalized swelling at Achilles tendon insertion
Bursitis of congenital/adventitious bursae
SynovitisDactylitis/'sausage' toe
Generalized swelling of fore foot
VasculitisNote: Does not tend to affect foot in sero-negative arthritides
RadiographsBone/periosteal fluffy/'whiskery' proliferation
New bone/spur formation at entheses, secondary to inflammation
Table 3: RICE(P)
RICE(P)Feature
R RestThe patient is advised to reduce/abstain from weight-bearing on the affected foot/limb until all symptoms subside
Joint immobilization is achieved by:
  • Soft splintage (retained strapping; padding; bandaging)

  • Rigid splintage (total-contact cast; AirCast boot; bivalve cast)

  • Walking aids (crutches; walking stick)

I Ice packsThe application of ice within 48-72 hours of the initial injury/onset of symptoms, to reduce swelling, minimize pain and control inflammation
Ice (cubes wrapped in a towel; packet of frozen peas; cool pack) is applied at least twice a day
Ice is not indicated >72 hours after injury; patients should be advised to apply gentle heat twice a day (immersion in water bath at 45°C for 10 minutes, infrared lamp, hot-water bottle)
C CompressionCompression bandaging (crepe bandage; Coban, 'figure of eight') controls soft-tissue oedema and reduces unwanted movement
E ElevationThe limb should be fully supported along its length, with the heel of the foot above hip height to minimize oedema
P Pain controlRest, ice (or heat), compression and elevation all help minimize pain, reduce inflammation and oedema
Non-steroidal anti-inflammatory drugs (e.g. 400 mg ibuprofen every 4 hours, or equivalent for 5 days) both reduce inflammation and control pain
Table 4: Techniques of strapping
StrappingApplication
Church doorThree lengths of strapping applied around the periphery of a pad, as a triangle
Goal postFour lengths of strapping applied around the periphery of a pad, as a rectangle
ShiplapSeveral lengths of strapping that are applied transversely across the pad from proximal to distal so that each subsequent strap overlaps the previous by one-third
FanSeveral lengths of strapping that are applied longitudinally across a joint (to form a soft splint), so that one end of each subsequent strap overlies the previous strap but the other end lies adjacent to the previous strap, so that the whole assemblage resembles a fan
Top strapThe distal transverse bar of goal post strapping, whose distal margin is shaped to reflect the line of the plantar webbing, allowing maximum plantar adhesion but minimal restriction of the toes
FlaskA strap cut to the shape of a bottle or flask, so that the 'neck' is applied to the pad, and the 'belly' to the skin
BananaA strap cut into the shape of a banana
Bow/false plantar fasciaLengths of strapping applied longitudinally along the sole of the foot from the heel to the plantar web line Figure 1
MaskSeveral layers of strapping laid one on another with a central hole cut to match the size of a lesion Figure 2
StirrupLengths of strapping applied to the ankle/subtalar joint area, applied from the medial to lateral malleolus (for a medial ankle sprain) or from the lateral to medial malleolus (for a lateral ankle sprain)
MetatarsalStrapping applied transversely across the plantar and dorsal surfaces of the forefoot to restrict metatarsal movement

Note: To aid retention, strapping should always be cut to create a smooth outline (e.g. corners are rounded) and applied firmly allowing for digital movement - unless the intention is to provide a soft splint to rest the part.

Figure 1: Bow strapping. A: Application of longitudinal straps B: Overlaying of transverse straps. This article was published in Neale's Disorders of the Foot, Lorimer, French, O'Donnell, Burrow, Wall, Copyright Elsevier, (2006).
Figure 2: Mask: several layers of adhesive strapping with a central hole into which a caustic ointment is placed (A), overlain by a cavitied felt pad (B), strapped into place (C). This article was published in Neale's Disorders of the Foot, Lorimer, French, O'Donnell, Burrow, Wall, Copyright Elsevier, (2006).