Lesser-toe deformity
Common patterns include:
- hammer toe: PIP flexion, often with MTP hyperextension
- mallet toe: DIP flexion
- claw toe: MTP hyperextension with PIP and DIP flexion
Assessment
Determine whether the deformity is:
- flexible or fixed
- isolated or part of global forefoot imbalance
- associated with MTP instability
- associated with hallux valgus, cavus or neurological disease
Look for dorsal corns, plantar callosity and crossover deformity.
Treatment
Non-operative:
- wide toe-box shoes
- toe pads or sleeves
- metatarsal offloading
- treatment of associated hallux or first-ray pathology
Surgical options depend on flexibility and level of deformity:
- tendon release or transfer
- PIP resection arthroplasty or fusion
- MTP soft-tissue balancing
- metatarsal shortening osteotomy in selected overload/instability patterns
Treating only the visible toe deformity while ignoring MTP instability or first-ray disease risks recurrence.
Flexible deformity may respond to footwear, pads, orthoses and management of the primary cause.
Surgical options depend on pathology and can include:
- tendon procedures
- PIP arthrodesis/resection arthroplasty
- plantar-plate repair
- metatarsal shortening osteotomy
- correction of associated hallux valgus
Initial measures:
- wide toe-box footwear
- metatarsal pad
- activity/footwear modification
- injection in selected patients
Persistent, well-localised symptoms may be treated surgically by decompression or neurectomy depending on technique and surgeon preference.
Morton's neuroma
Morton's neuroma is a compressive/degenerative interdigital nerve disorder, most commonly in the third web space.
Presentation
- burning forefoot pain
- radiation into adjacent toes
- worse in tight footwear
- intermittent paraesthesia
Examination
- web-space tenderness
- pain with forefoot compression
- palpable or audible click may occur
Differential diagnosis
- MTP synovitis or instability
- stress fracture
- Freiberg disease
- plantar-plate pathology
- inflammatory arthritis
Treatment
Start with footwear modification and metatarsal offloading. Image-guided injection may be used selectively. Persistent disabling symptoms can be treated with decompression or neurectomy after confirming the diagnosis and discussing numbness and recurrence risk.
Lesser-toe deformities
Common patterns include:
- hammer toe: predominant PIP flexion
- mallet toe: predominant DIP flexion
- claw toe: MTP hyperextension with PIP/DIP flexion
The key distinction is whether the deformity is flexible or fixed and whether MTP instability is present.
Causes
Look for:
- footwear pressure
- hallux valgus
- long second metatarsal or forefoot loading
- inflammatory disease
- neurological imbalance
- intrinsic muscle dysfunction
- plantar-plate failure
Do not treat the toe in isolation if the driving forefoot mechanics are uncorrected.
Examination
Assess:
- passively correctable versus fixed deformity
- MTP drawer/instability
- plantar callosity
- dorsal corns
- hallux valgus
- metatarsalgia
- neurovascular status
Morton's interdigital neuropathy
This is a painful interdigital nerve condition, most commonly involving the third web space.
Symptoms include:
- burning forefoot pain
- radiation into adjacent toes
- worse symptoms in tight footwear
- relief on removing the shoe
- paraesthesia or numbness
The pathology is not a true neoplasm; repetitive compression and fibrosis around the common plantar digital nerve are central concepts.
Diagnosis
Clinical examination may reproduce pain with web-space compression and forefoot squeeze. A Mulder-type click may be present but is not mandatory.
Ultrasound or MRI can support the diagnosis when uncertainty remains, but imaging findings must correlate with symptoms.
Complications of neurectomy
Important issues include:
- numbness in adjacent toes
- stump neuroma
- persistent pain
- wrong-level surgery
- scar sensitivity
FRCS synthesis
For lesser-toe or neuroma cases, the examination should extend to the whole forefoot. The key question is whether the local lesion is the primary problem or a consequence of a broader mechanical deformity.