Mallet toe is a deformity of the distal interphalangeal joint (DIPJ) of the lesser toes, typically involving flexion of the distal phalanx while the proximal interphalangeal (PIP) and metatarsophalangeal (MTP) joints remain neutral. The condition may be flexible or fixed and is often caused by chronic mechanical pressure or tendon imbalance. It can lead to pain, callus formation, and difficulty wearing shoes. Although less common than hammer toe or claw toe, mallet toe remains an important cause of forefoot pain and functional limitation.
How Common It Is and Who Gets It? (Epidemiology)
Mallet toe most often affects adults between 40 and 70 years old and is slightly more common in women, reflecting footwear habits such as tight or high-heeled shoes. The second toe is most commonly involved, particularly when it is longer than the great toe. The deformity can occur unilaterally or bilaterally, and up to 70% of cases are associated with a longer digit or hallux valgus deformity. It is frequently seen in patients with diabetes, rheumatoid arthritis, or neuromuscular disorders that cause muscle imbalance in the toes.
Why It Happens – Causes (Etiology and Pathophysiology)
Mallet toe results from an imbalance between the flexor and extensor tendons acting on the DIP joint:
- Flexor digitorum longus (FDL) contracts excessively, overpowering the extensor digitorum longus (EDL).
- Rupture or attenuation of the EDL at the DIP joint can also lead to unopposed flexion.
- Chronic pressure from shoes against the toe tip can stimulate flexor contraction and lead to progressive joint deformity.
- Trauma, such as stubbing the toe, or inflammatory conditions like rheumatoid arthritis, can precipitate the condition.
The deformity can be: - Flexible: The toe can be passively straightened.
- Rigid: Long-standing contracture where the toe cannot be extended manually.
How the Body Part Normally Works? (Relevant Anatomy)
Each lesser toe consists of three phalanges and three joints (MTP, PIP, DIP).
- FDL flexes the DIP joint.
- EDL and EDB extend the DIP and PIP joints.
- When balanced, these muscles allow the toe to bend and extend evenly during gait.
In mallet toe, the overactive FDL flexes the distal phalanx while the extensor mechanism becomes weakened or ruptured, fixing the toe in flexion.
What You Might Feel – Symptoms (Clinical Presentation)
- Pain or tenderness at the tip of the affected toe or on the dorsum of the DIP joint.
- Corns or calluses on the tip of the toe or under the nail from repetitive pressure.
- Redness, swelling, and sometimes ulceration over the DIP joint in rigid deformities.
- Difficulty finding comfortable shoes or wearing dress footwear.
- In chronic cases, nail deformities may develop due to repeated trauma to the nail bed.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is clinical and based on physical examination:
- Observation of flexion deformity at the DIP joint with normal alignment at the PIP and MTP joints.
- Palpation reveals tender calluses or corns at the toe tip or dorsum of the joint.
- Flexibility testing: Determines whether the deformity is flexible or rigid.
- Radiographs: Lateral and oblique foot X-rays may show increased DIP joint flexion, callus formation, or degenerative changes.
Imaging is usually not necessary unless trauma or arthritis is suspected.
Classification
- Flexible Mallet Toe: Deformity corrects with manual manipulation.
- Rigid Mallet Toe: Fixed flexion due to joint capsule contracture or bone adaptation.
- Congenital Mallet Toe: Present at birth, often associated with flexion and lateral deviation of the DIP joint.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Hammer toe (PIP joint flexion deformity).
- Claw toe (hyperextension at MTP and flexion at both PIP and DIP joints).
- Freiberg’s infraction (metatarsal head necrosis).
- Morton’s neuroma or metatarsalgia causing forefoot pain.
- Arthritis or post-traumatic deformities.
Treatment Options
Non-Surgical (Conservative) Management
Conservative care is the first-line approach for flexible deformities and symptom relief:
- Footwear modification: Use shoes with high, wide toe boxes to reduce pressure.
- Padding: Silicone or foam toe sleeves protect calluses and corns.
- Orthotics: Metatarsal pads and soft insoles relieve forefoot pressure.
- Toe splints or crests: Hold the DIP joint in a neutral position and correct mild deformities.
- Stretching exercises: Target the flexor tendons to improve flexibility.
- Callus care: Regular debridement or pumice stone use to reduce friction.
For patients with diabetes or vascular compromise, avoid aggressive mechanical correction to prevent ulceration.
Surgical Care
Surgery is indicated for rigid deformities, failed conservative therapy, or ulceration. The procedure depends on deformity severity and flexibility:
- Percutaneous or Open Flexor Tenotomy
- Most common and least invasive surgical option.
- Involves cutting the FDL tendon to release the flexion deformity.
- Indicated for flexible mallet toes unresponsive to conservative measures.
- May be done under local anesthesia; K-wire fixation can maintain alignment during healing.
- FDL Tendon Transfer (Girdlestone-Taylor Procedure)
- Transfers the FDL tendon to the dorsal aspect of the distal phalanx to prevent unopposed flexion and correct residual cock-up deformity.
- Indicated when extensor tendons are attenuated.
- DIP Joint Fusion (Arthrodesis)
- Recommended for rigid deformities or degenerative joint disease.
- Joint surfaces are resected, and a K-wire or screw is placed to achieve fusion.
- Provides durable pain relief but sacrifices motion at the DIP joint.
- Middle Phalangeal Distal Condylectomy (Excisional Arthroplasty)
- Removal of part of the middle phalanx to realign the toe.
- Indicated in rigid deformities where DIP fusion is undesirable.
- Distal Phalangectomy
- Rarely performed except in elderly or medically complex patients.
- Removes the distal phalanx, effectively eliminating the deformity but shortening the toe.
Recovery and What to Expect After Treatment
- Conservative care: Relief often within weeks with proper shoes and padding.
- Surgery: Outpatient procedure; weight-bearing allowed in a surgical shoe after 1–2 weeks.
- Sutures removed after 10–14 days.
- K-wire (if used) removed after 3–4 weeks.
- Full recovery and return to regular footwear typically occur within 6–8 weeks.
Possible Risks or Side Effects (Complications)
- Recurrence of deformity, particularly after simple tenotomy.
- Infection or delayed wound healing.
- Numbness or sensory changes from nerve irritation.
- Floating toe or overcorrection.
- Nonunion after fusion procedures.
Long-Term Outlook (Prognosis)
The prognosis for mallet toe is excellent when treated early and appropriately. Non-surgical care effectively relieves symptoms in most flexible deformities. Surgical correction provides long-term stability and pain relief in rigid or recurrent cases. Functional outcomes are favorable, and recurrence rates are low when tendon balance is restored.
Out-of-Pocket Costs
Medicare
CPT Code 28272 – Flexor Tenotomy (Soft Tissue Release): $86.37
CPT Code 28285 – Hemiphalangectomy / Condylectomy / Arthrodesis / DIPJ Resection Arthroplasty: $123.92
CPT Code 28820 – Distal Phalangectomy (Amputation): $67.24
Medicare Part B typically covers 80% of the approved cost for these procedures after your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining portion, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These supplemental plans coordinate with Medicare to fill the coverage gap and reduce financial responsibility.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer. These plans usually cover any remaining balance, including coinsurance or small deductibles, which typically range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your mallet toe deformity developed due to a work-related injury or repetitive stress, Workers’ Compensation will cover all related medical expenses, including surgery, rehabilitation, and postoperative care. You will have no out-of-pocket costs, as the employer’s insurance carrier directly covers all approved procedures.
No-Fault Insurance
If your mallet toe deformity or resulting pain was caused or aggravated by an automobile accident, No-Fault Insurance will typically cover the entire cost of treatment, including surgery and follow-up care. The only possible out-of-pocket cost may be a small deductible or co-payment, depending on your policy.
Example
Robert Hayes suffered from a painful mallet toe deformity that limited his mobility. He underwent flexor tenotomy (CPT 28272) followed by resection arthroplasty (CPT 28285). His estimated Medicare out-of-pocket cost for the arthroplasty was $123.92. Since Robert had supplemental coverage through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is mallet toe?
A. Mallet toe is a deformity where the joint at the end of the toe becomes bent, leading to a curled toe appearance.
Q. Which toe is most commonly affected by mallet toe?
A. The second toe is most commonly affected by mallet toe, although it can affect any toe.
Q. What causes mallet toe?
A. Mallet toe can be caused by muscle imbalance, trauma, poorly fitting shoes, or underlying conditions like diabetes or arthritis.
Q. What are the symptoms of mallet toe?
A. Symptoms include pain, redness, swelling at the toe joint, corns or calluses from friction, and difficulty wearing shoes.
Q. How is mallet toe diagnosed?
A. Mallet toe is diagnosed through a physical examination and confirmed with X-rays to evaluate the bone alignment and severity.
Q. What non-surgical treatments are available for mallet toe?
A. Non-surgical treatments include wearing roomier footwear, using toe pads or cushions, performing stretching exercises, and managing underlying conditions.
Q. When is surgery recommended for mallet toe?
A. Surgery is recommended when conservative treatments fail to relieve symptoms or if the deformity is rigid and painful.
Q. What types of surgery are performed for mallet toe?
A. Surgical options include tendon lengthening or transfer, joint fusion, or removal of part of the bone to straighten the toe.
Q. What is the recovery time after surgery for mallet toe?
A. Recovery may take several weeks, during which time patients may need to wear a special shoe and limit weight-bearing activity.
Q. Can mallet toe come back after treatment?
A. Recurrence is possible, especially if underlying causes are not addressed or proper footwear is not used.
Q. How can mallet toe be prevented?
A. Mallet toe can be prevented by wearing well-fitting shoes with adequate toe room, avoiding high heels, and addressing foot muscle imbalances early.
Summary and Takeaway
Mallet toe is a flexion deformity of the distal joint in a lesser toe, caused by chronic pressure, tendon imbalance, or trauma. Diagnosis is clinical, based on DIP joint flexion with neutral PIP and MTP joints. Initial treatment focuses on footwear modification and protective padding. Surgery—typically flexor tenotomy, tendon transfer, or DIP fusion—is reserved for rigid deformities or failed conservative care. Early intervention and proper footwear yield excellent functional and cosmetic results.
Clinical Insight & Recent Findings
A 2023 case report from Journal of Surgical Case Reports described a novel approach for treating bony mallet toe of the hallux (big toe) using screw fixation with FiberWire suture augmentation.
The 54-year-old patient had an avulsion fracture of the distal phalanx that was surgically repaired with two 1.5 mm screws and reinforced sutures, followed by temporary joint fixation for four weeks. At 20-month follow-up, the patient regained full motion and had no pain, deformity, or complications.
The authors concluded that combining small screw fixation with suture reinforcement provides strong, stable fixation and may shorten immobilization time—offering an effective option for this rare injury where standard treatment guidelines remain unclear. (“Study on successful screw-and-suture repair for big-toe mallet injury – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Treatment is typically managed by orthopedic foot and ankle surgeons or podiatric surgeons, often supported by physical therapists for postoperative rehabilitation.
When to See a Specialist?
Consult a specialist if you experience persistent toe pain, corns, or visible deformity that interferes with footwear or daily activities.
When to Go to the Emergency Room?
Emergency care is rarely needed unless there is severe infection, ulceration, or trauma to the affected toe.
What Recovery Really Looks Like?
Patients can expect progressive pain relief and improvement in function within weeks of treatment. Surgical cases require short-term immobilization but typically result in a stable, pain-free toe.
What Happens If You Ignore It?
Untreated mallet toe can become rigid, leading to chronic pain, callus formation, and ulceration—particularly in diabetic patients. Over time, compensatory deformities or altered gait mechanics may develop.
How to Prevent It?
- Wear properly fitted shoes with adequate toe room.
- Avoid prolonged use of high heels.
- Stretch and strengthen the toe and foot muscles regularly.
- Address bunions or forefoot deformities early to prevent secondary toe imbalance.
Nutrition and Bone or Joint Health
Maintain adequate calcium, vitamin D, and protein intake to support joint and tendon health. Anti-inflammatory foods, hydration, and healthy weight management reduce foot stress.
Activity and Lifestyle Modifications
Opt for supportive shoes, use cushioned insoles, and perform daily toe stretches to maintain flexibility. Avoid repetitive trauma to the toe tip. For postoperative recovery, gradually resume normal activities while protecting the toe from excess pressure.
Dr. Mo Athar
