HAMMER, MALLET OR CLAW, OH MY!

Hammer toes, Mallet toes and Claw toes are three types of digital deformities of the foot that are extremely similar, yet vary from one another depending on the joint within the toe that is most affected. The term “hammer toe” is often used to encompass all three deformities, but they are distinct entities. To make the distinction relatively simple, remember that each of your toes, numbers 2 through 4 have three joints. In a hammer the middle of those three joints is the cause of the deformity, where as in claw toes it is both the middle and end joints and for mallet toes it’s only the end joint.

Digital deformities of this type are typically a result of muscular imbalance within the foot. What does that mean? Each of us is made with a different foot type and although some of us are perfect, or have perfect feet, we only make up about 20% of the population. That means that the other 80% of the population have a foot type that predisposes them to some type of deformity during their life; whether that be hammer toes, bunions, flatfeet etc. If you think about those statistics, abnormal is normal and normal is abnormal when talking about our feet! Either way, your body and more importantly your toes attempt to compensate for the muscular imbalances within the foot to increase foot function, and as a result they hammer, or contract at one or several of the joints within the toe.

Some less common causes of hammer, mallet or claw toes include joint diseases, such as rheumatoid arthritis, spinal cord or nerve injuries which weaken the muscles within the foot, decreased blood flow and decreased feeling in the toes, and a history of trauma to the toe such as fracture.

Prevention of digital deformity is much the same as preventative methods for development of bunions (hallux abducto valgus), which we discussed over the last two weeks. The etiology of the deformity must be identified early and corrected so that the foot never needs to compensate for that abnormality. Certainly wearing comfortable and supportive shoes, contrary to shoving toes into “pointy-toed” stilettos will decrease your chances of developing hammertoes, but it is a deformity that is much less predictable for occurrence than some other more debilitating and noticeable deformities of the foot.

The primary patient concern with this type of deformity includes corns that develop on the top of the affected digit and increased pain while wearing shoes due to increased pressure over the toe. It is likely and prudent that your doctor will suggest conservative treatments prior to any surgical interventions, although both are viable options. To decrease such symptoms conservatively and make the deformity more manageable, your Podiatrist can trim the corns down. By taking down the dead skin, the pressures over the toe will become less and pain will also decrease. Your Podiatrist will also recommend padding of the toe to eliminate pressure created between your toe and the shoe. They may use a strapping device that will “buddy” the toe to a more stable digit, bringing it down into line with the other digits. Of course, wearing shoes with a wider and roomier toe box will alleviate pressures and decrease pain as well. Injection therapy is not a conservative treatment that is offered due to the size of the digit and the minimal degree of relief that it may provide.

If patients can tolerate padding in their shoes and occasional trimming of their corns, conservative care of the deformity can provide a long-term result. It is likely that decreasing such pressures will decrease symptoms and hammer toes can become quite manageable conservatively! If all conservative treatments fail and you are ready to consent for a surgical approach to fixing your hammer, mallet or claw toe, your Podiatrist can certainly recommend something that will reduce pain and pressures. Next week we will discuss the surgical options for treating your deformity including what to expect after surgical correction.

Should I Have My Bunion Repaired?

This week we will focus on the types of surgical procedures used to correct painful bunion deformities that have not responded to conservative care. To reiterate, conservative treatment options should be considered and exhausted when possible before surgery becomes a reality. Types of conservative care include injections, padding/offloading and orthotic therapy. When conservative therapy fails your Podiatrist may recommend surgical correction through one of the procedures described below in attempt to realign the big toe and decrease the level of pain you have been experiencing. It is important to keep in mind when reviewing these procedures that your Podiatrist will select the right procedure for you based on the severity of your deformity.

Soft Tissue Procedures: A soft tissue procedure used for bunion correction is one that attempts to release any tendons and tighten the capsule around the involved joint, both of which are involved in deviating the big toe towards the lesser toes. By releasing these pieces of soft tissue the bones within the big toe will straighten out, align with the lesser toes and decrease the space that has been created between the first and second long bones in the foot. Typically, these procedures are used on patients who have mild deformities and minimal pain over the bump on their big toe. Soft tissue procedures can be performed alone, but are always performed when more corrective procedures are also performed.

Bone Procedures: There are two types of bone procedures that can be used to correct your bunion deformity. There is one procedure where cuts are made into the first long bone of the foot and another procedure where cuts are made in to one of the two bones in the big toe.

Procedures that make cuts into the first long bone of the foot are used for moderate deformities where there is a more significant deviation of the big toe towards the lesser toes. Patients who require such procedures typically have moderate pain that would not adequately reduce with only a soft tissue procedure. In bone procedures, a “V-shaped” cut is made in the first long bone of the foot allowing the bone to be shifted over, aligned with the lesser toes and held in place with a pin or screw.

Procedures that make cuts into one of the two bones in the big toe are used when one of those two bones are a contributing factor in the deformity. A wedge cut is made in one of the bones in the big toe and the bone is de-rotated and properly aligned with the long bone in the foot as well as with the lesser toes. It is stabilized with a pin or screw; the same pin or screw being used for fixation of the bone cut made in the long bone of the foot as described above.

Fusion Procedures: A fusion procedure is used when patients have big toe joints that are arthritic and destroyed, thus they cannot function even if the bones are placed in a corrected position, as would be done with a bone procedure. A fusion procedure removes any material within the joint space that is destroyed and places the long bone in the foot and the first bone in the big toe together, end-to-end. A pin or screw is used for fixation and after 6-8 weeks of healing, the joint is fused and motion is permanently eliminated. Elimination of movement at the joint significantly decreases pain in patients with such conditions.

As with any surgical procedure the risks and benefits should be considered and discussed with your Podiatrist. Complications with any of the bunion procedures described above can include infection, scarring, recurrence of deformity, and transfer pain among others, although the risks of any such complications are minimal. Patients should expect anywhere from 2-8 weeks of recovery depending on the procedure selected and they should expect pain during recovery; although pain is a personal thing and depends on the patients tolerance!

Bunions are Genetic, Aren’t They?

This question can be heard multiples times per week in a Podiatrists’ office, and the answer to the questions is: No, not exactly! Bunions have a variety of etiologies that can act alone or in combination with one another causing deformity of the first ray (1^st metatarsal and bones of the 1^st toe). Just because Mom or Pop may have a bunion, you didn’t inherit your bunions from them, you inherited their abnormal foot type.

Lets take a step backwards for a minute and talk about what exactly a bunion is. Hallux Abducto Valgus (bunion) is a triplanar, progressive deformity of the first metatarsal in which the hallux (great toe) is deviated towards the lesser toes (abducted) and rotated (valgus). HAV is one of the most common pathologies found in the lower extremity and is found in females more often than males by about a 4:1 ratio.

The most common etiology can be classified as a biomechanical abnormality: any condition whereby the 1^st ray cannot function optimally in comparison to the normal or rectus foot. This encompasses a variety of pathologies including a hypermobile first ray (excessive motion of the 1^st metatarsal and its articulations within the foot), inflammatory conditions of the 1^st joint, neuromuscular diseases, an elevated first ray (met primus elevatus), and metatarsus adductus (medial deviation of metatarsals 2-5), to name a few. These inherited conditions prohibit the foot from functioning optimally and your body is forced to compensate for such abnormalities leading to the formation of a bunion. Thanks Mom and Dad!!

Some other less common etiologies of Hallux Abducto Valgus include post-surgical malformation, equinus (inability to dorsiflex the ankle greater than 10 degrees past neutral), limb length discrepancies, and a history of trauma to the hallux.

To prevent the occurrence of bunions, one of the predisposing conditions must be identified and corrected early on, or avoided all together. Unfortunately, this is not typically the case with inherited biomechanical abnormalities. The conditions go unnoticed or are brushed-off as something that the child will “outgrow.” Most pediatric foot abnormalities will not be outgrown and early evaluation and identification of a pathology by a Podiatrist can allow the child to be monitored and/or treated conservatively throughout their development.

Treatments options include a vast array of choices from conservative to surgical and the choice depends largely on the patients pain and discomfort in combination with a physical and clinical examination of the condition. Your Podiatrist will ask you a variety of questions to determine how fast the deformity is progressing and what methods of treatment, if any, you have previously tried. They will examine the deformity clinically to determine where the pain is localized, the degree of soft tissue involvement, the condition of the joint, the rigidity of deformity, and the underlying etiology. Your Podiatrist will also take bilateral radiographs of your feet to evaluate the joint and bone positions in comparison to “standard” radiographic angles.

Once all the pieces of the examination have been considered together, it is most likely that conservative options will be exhausted prior to surgical intervention. Conservative treatments include: injections to decrease inflammation and alleviate pain; padding of the toe to decrease pressure with shoes; physical therapy to increase the range of motion at the joint and eliminate muscular imbalances that may be a causative factor; and orthotics, which attempt to realign the foot in a more optimal position decreasing the biomechanical abnormality that may be the root etiology of your HAV.

If the deformity is rigid and severely progressed, or if conservative treatments have been exhausted without resolution of pain, surgical options become a consideration. Next week we will discuss the types of surgical procedures that may be performed in treating your bunion, the pros and cons of such surgeries and the pre-operative and post-operative courses that should be expected.