Lesser toe deformities are common disorders affecting the second through fifth toes. They can cause significant pain, difficulty walking, and problems wearing shoes. These deformities arise from structural and functional imbalances in the toes’ joints, tendons, and supporting soft tissues. While often progressive, most cases respond well to early intervention through footwear modification, orthotics, or surgery when needed.
How Common It Is and Who Gets It? (Epidemiology)
Lesser toe deformities are highly prevalent, particularly among middle-aged and older adults, and are more common in women due to footwear choices and coexisting forefoot deformities such as hallux valgus (bunion). Studies suggest that up to 20–30% of adults over age 40 show some degree of toe deformity. The risk increases with age, diabetes, rheumatoid arthritis, and high-heel or tight-fitting shoes. The second toe is most frequently affected, particularly in association with bunions.
Why It Happens – Causes (Etiology and Pathophysiology)
The primary cause of lesser toe deformities is muscle-tendon imbalance affecting the metatarsophalangeal joint (MTPJ), proximal interphalangeal joint (PIPJ), and distal interphalangeal joint (DIPJ). When the flexor and extensor tendons overpower weakened intrinsic toe muscles, the joints become misaligned.
Common contributing factors include:
- Footwear: High heels or tight shoes that force toes into flexed positions.
- Forefoot deformities: Hallux valgus and metatarsalgia increase pressure on the lesser toes.
- Trauma: Fractures, dislocations, or tendon injuries.
- Systemic disease: Rheumatoid arthritis, diabetes, and neuromuscular disorders.
- Genetics and anatomy: High arches (pes cavus) or long second toes predispose to deformity.
How the Body Part Normally Works? (Relevant Anatomy)
Each lesser toe consists of three phalanges (proximal, middle, distal) that articulate with the metatarsals at the MTP joints.
- Flexors (FDL and FDB): Curl the toes downward.
- Extensors (EDL and EDB): Lift the toes upward.
- Intrinsic muscles: Stabilize toe position and assist with balance during walking.
When balanced, these muscles allow proper toe alignment during gait. Disruption of this balance—by shoe pressure, ligament laxity, or intrinsic weakness—leads to deformities.
What You Might Feel – Symptoms (Clinical Presentation)
- Visible bending or curling of one or more toes.
- Pain, particularly over bony prominences or the ball of the foot (metatarsalgia).
- Corns or calluses on the tops or tips of toes due to shoe friction.
- Difficulty finding comfortable footwear.
- Redness or irritation on pressure points.
- In severe cases, overlapping or crossing of toes.
Types of Lesser Toe Deformities
- Claw Toe:
- Hyperextension at the MTPJ and flexion at both PIPJ and DIPJ.
- Commonly linked to neurological disorders or advanced rheumatoid arthritis.
- Causes prominent dorsal calluses and pain under the metatarsal heads.
- Hammer Toe:
- Flexion at the PIPJ with possible hyperextension at the MTPJ.
- Typically affects the second toe and may accompany bunions or flatfoot.
- Leads to painful corns over the PIPJ.
- Mallet Toe:
- Flexion deformity at the DIPJ only.
- Often results from ill-fitting shoes or trauma to the toe tip.
- Causes pressure sores or calluses on the toe tip.
- Crossover Toe:
- The toe deviates laterally or medially, often overlapping another toe.
- Most commonly affects the second toe and is frequently associated with hallux valgus and plantar plate injury.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a thorough clinical examination.
- Physical Exam: Evaluates deformity type, flexibility (rigid vs. flexible), calluses, and skin breakdown. The Lachman test (dorsal drawer test) detects MTPJ instability.
- Imaging:
- X-rays: Show joint alignment, bone deformity, or arthritis.
- MRI or ultrasound: Useful for evaluating soft-tissue injuries such as plantar plate tears or capsulitis.
- MRI arthrogram: Helpful in complex cases of MTPJ instability.
Classification
Deformities are categorized as:
- Flexible: The toe can be manually straightened; early and reversible.
- Rigid: The deformity is fixed; long-standing and may require surgery.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Plantar plate rupture.
- Morton’s neuroma (nerve pain between toes).
- Freiberg’s infraction (avascular necrosis of metatarsal head).
- Rheumatoid arthritis-related deformities.
- Post-traumatic arthritis or dislocation.
Treatment Options
Non-Surgical (Conservative) Management
Mild or early-stage deformities often improve with conservative measures:
- Footwear modification: Wide toe-box shoes, low heels, and cushioned insoles reduce pressure.
- Orthotics: Metatarsal pads or off-loading insoles redistribute pressure from painful metatarsal heads.
- Padding and toe sleeves: Silicone cushions reduce friction and protect prominent joints.
- Stretching and strengthening: Toe exercises and intrinsic muscle training improve flexibility.
- Splints or taping: Toe alignment splints can correct mild deformities.
- Steroid injections: Helpful for capsulitis or bursitis around the MTPJ to relieve pain.
Surgical Care
Surgery is indicated when conservative treatments fail or deformities become rigid and painful. Surgical goals are to restore alignment, relieve pain, and maintain toe stability.
- MTPJ instability repair: Soft-tissue procedures such as extensor tendon lengthening, capsulotomy, or flexor-to-extensor tendon transfer correct joint imbalance.
- Osteotomy procedures:
- Weil osteotomy shortens the metatarsal to relieve pressure and realign the toe.
- Proven to reduce metatarsalgia and improve walking comfort.
- Tendon transfers:
- The Girdlestone-Taylor flexor-to-extensor transfer restores balance and corrects claw or hammer toes.
- Flexor tenotomy:
- Performed for mallet or flexible hammer toes to release tight tendons.
- Joint fusion (arthrodesis):
- For rigid deformities, fusing the PIPJ provides permanent correction and pain relief.
- Crossover toe correction:
- May require complex soft-tissue releases, Weil osteotomy, and flexor-to-extensor transfer.
Minimally Invasive Surgery
Recent techniques, including percutaneous tenotomy and distal metatarsal metaphyseal osteotomy (DMMO), minimize soft-tissue trauma. Benefits include smaller scars, faster recovery, and reduced postoperative pain, though surgeon experience is essential to avoid complications.
Recovery and What to Expect After Treatment
- Non-surgical treatment: Symptom relief usually occurs within 4–6 weeks with proper footwear and orthotics.
- Surgical recovery:
- Partial weight-bearing begins after 2–3 weeks.
- Sutures are removed after 10–14 days.
- Full recovery typically takes 6–12 weeks, depending on the procedure.
Physical therapy after surgery is crucial to regain strength and mobility.
Possible Risks or Side Effects (Complications)
- Recurrence or overcorrection (floating toe or stiffness).
- Infection or delayed wound healing.
- Nerve irritation or numbness.
- Persistent pain or residual deformity.
- Transfer metatarsalgia (pain shifting to adjacent toes).
Long-Term Outlook (Prognosis)
The prognosis is generally excellent when deformities are identified early and treated appropriately. Non-surgical management provides lasting relief for flexible deformities, while surgical correction yields good outcomes in rigid cases. Proper footwear and preventive care minimize recurrence.
Out-of-Pocket Costs
Medicare
CPT Code 28285 – Correction, Hammertoe (e.g., Interphalangeal Fusion, Partial or Total Phalangectomy, Single Toe): $123.92
CPT Code 28286 – Correction, Rigid Claw Toe, Includes Resection of Proximal Phalanx Head (Single Toe): $99.54
CPT Code 28288 – Reconstruction, Complex, of Lesser Toe Deformity (e.g., Crossover Toe Correction with Soft Tissue and Bony Procedures): $137.73
CPT Code 28308 – Osteotomy, Lesser Metatarsal (e.g., Weil Osteotomy) to Shorten or Realign Metatarsal Head: $130.95
CPT Code 28313 – Reconstruction, Angular Deformity of Toe (e.g., Rotational Osteotomy): $613.27
CPT Code 28270 – Capsulotomy, Metatarsophalangeal Joint, Single: $111.18
CPT Code 28272 – Tenotomy, Open, Flexor, Single Toe (Used for Flexor Tenotomy): $86.37
Medicare Part B covers 80% of the approved cost for these procedures once 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 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These supplemental plans are designed to work with Medicare and fill the coverage gap.
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 often 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 lesser toe deformity developed due to repetitive strain or a work-related injury, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier pays directly for all approved treatments.
No-Fault Insurance
If your foot deformity or associated pain resulted from an automobile accident, No-Fault Insurance will typically cover the full cost of your treatment, including surgical and postoperative care. The only possible out-of-pocket cost may be a small deductible or co-payment based on your policy.
Example
Emily Rogers had painful rigid claw toe deformities requiring hammertoe correction (CPT 28285) and Weil osteotomy (CPT 28308). Her estimated Medicare out-of-pocket cost for the primary procedure was $123.92. Since Emily had supplemental insurance through AARP Medigap, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the surgery.
Frequently Asked Questions (FAQ)
Q. What are lesser toe deformities?
A. Lesser toe deformities refer to abnormalities in the second, third, fourth, or fifth toes that affect their position, shape, or function.
Q. What are common types of lesser toe deformities?
A. Common types include hammer toe, claw toe, and mallet toe.
Q. What causes lesser toe deformities?
A. Causes include muscle imbalance, trauma, arthritis, ill-fitting footwear, and underlying neurological conditions.
Q. How does muscle imbalance lead to lesser toe deformities?
A. Muscle imbalance can cause the tendons to pull unevenly on the toes, resulting in abnormal toe positions.
Q. How can trauma cause lesser toe deformities?
A. Trauma such as fractures or dislocations can disrupt normal alignment and function of the toes.
Q. How does arthritis contribute to lesser toe deformities?
A. Arthritis can cause joint inflammation and damage, leading to deformities in the toes.
Q. Can shoes cause lesser toe deformities?
A. Yes, tight or ill-fitting shoes can force the toes into abnormal positions over time.
Q. What are the symptoms of lesser toe deformities?
A. Symptoms include toe pain, swelling, difficulty wearing shoes, corns, calluses, and visible toe abnormalities.
Q. How are lesser toe deformities diagnosed?
A. Diagnosis involves a physical examination and may include X-rays to assess the extent of deformity.
Q. What non-surgical treatments are available for lesser toe deformities?
A. Non-surgical treatments include changing footwear, using orthotics, toe exercises, and padding for corns and calluses.
Q. When is surgery considered for lesser toe deformities?
A. Surgery is considered when non-surgical treatments fail to relieve symptoms or the deformity is severe.
Q. What surgical options are available for lesser toe deformities?
A. Surgical options may include tendon releases, tendon transfers, joint fusion, or bone resection.
Q. How long is the recovery after surgery for lesser toe deformities?
A. Recovery can vary but typically involves several weeks to months, including rest, limited weight-bearing, and physical therapy.
Q. Can lesser toe deformities recur after treatment?
A. Yes, recurrence is possible, especially if underlying causes like improper footwear or systemic conditions are not addressed.
Q. How can I prevent lesser toe deformities?
A. Prevention strategies include wearing properly fitting shoes, avoiding high heels, and performing toe strengthening exercises.
Summary and Takeaway
Lesser toe deformities—including claw, hammer, mallet, and crossover toes—arise from muscle-tendon imbalance and mechanical stress. Early recognition allows for effective non-surgical management through footwear modification and orthotics. For rigid or painful deformities, modern surgical techniques such as tendon transfers, Weil osteotomy, or minimally invasive procedures can restore alignment and relieve pain. Individualized treatment based on deformity type and patient needs leads to excellent long-term outcomes.
Clinical Insight & Recent Findings
A recent study published in the Archives of Orthopaedic and Trauma Surgery introduced a minimally invasive flexor tenodesis procedure for treating lesser toe deformities.
The technique anchors both the flexor digitorum longus and brevis tendons to the base of the toe bone using a small implant, restoring proper alignment and function while minimizing stiffness. In a small group of patients, the approach achieved excellent correction and pain relief without complications such as floating toe or joint stiffness.
These findings highlight flexor tenodesis as a promising modern option for patients requiring surgical correction of lesser toe deformities. (“Recent study on flexor tenodesis for lesser toe deformities – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Treatment is typically managed by orthopedic foot and ankle surgeons or podiatric surgeons, supported by physical therapists and orthotists for postoperative rehabilitation and orthotic design.
When to See a Specialist?
See a foot and ankle specialist if you experience chronic toe pain, corns, calluses, or visible deformity that interferes with daily activities or shoe wear.
When to Go to the Emergency Room?
Go to the ER only for acute trauma, open wounds, or infection (redness, swelling, drainage) involving the toes.
What Recovery Really Looks Like?
Recovery varies depending on the procedure but typically involves temporary off-loading, gradual return to normal footwear, and physical therapy. Long-term comfort and function are restored in most cases.
What Happens If You Ignore It?
Untreated deformities can lead to worsening pain, rigid contractures, ulcers, and difficulty walking. Advanced cases may require more extensive surgery for correction.
How to Prevent It?
- Wear supportive, properly fitting shoes.
- Avoid prolonged high-heel use.
- Perform toe-strengthening and stretching exercises regularly.
- Manage systemic diseases that affect joint and tendon health.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and omega-3 fatty acids supports joint health and tissue repair. Adequate hydration and maintaining healthy body weight reduce foot stress.
Activity and Lifestyle Modifications
Use cushioned insoles and shoes with wide toe boxes. Incorporate daily stretching and balance exercises. Avoid repetitive high-impact activities that overload the forefoot. With consistent preventive care, most patients maintain pain-free mobility and prevent recurrence.
Dr. Mo Athar
