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Hammertoes, the most common toe
contractures, are contracted at the first toe joint. (See
diagram to the left.) Mallet Toes
are contracted at the second toe joint, the joint right behind the
toe nail. Claw toes are
contracted at both joints.
Each of these conditions can be quite uncomfortable and cosmetically unappealing. |
What kind of troubles do contracted toes give you?
Some people never have troubles with their contracted toes. In fact, some people don't even know they have them. But they can become uncomfortable, especially while wearing shoes. Many people who develop symptoms with contracted toes will develop corns, blisters and pain on the top of the toe, where it rubs against the shoe--or between the toes, where it rubs against the adjacent toe. You can also develop calluses on the balls of the feet, as well as cramping, aching and an overall fatigue in the foot and leg.
Who can get a contracted toe?
Anyone can develop a contracted toe, though it is more common with women.
Why do people get contracted toes?
Contracted toes can result from or be worsened by a number of factors. Poor shoe choices, trauma, infection, arthritis, neurological conditions, and genetics may all play a role in the development of contracted toes, but the most common way to develop a contracted toe is through various biomechanical abnormalities in how you walk.
What kind of biomechanical abnormalities?
There are three major biomechanical mechanisms that may cause contracted toes. Extensor Substitution is the condition where a patient has weak muscles on the front of the leg, and an extra muscle on the front of the leg, (the Extensor Digitorum Longus muscle), is recruited to help the foot swing forward in gait. Because this muscle is attached to the toes by a tendon, the constant pathological pull of this tendon may frequently cause the toes to contract over time. Flexor Substitution is the condition where weak muscles on the back of the calf necessitate the recruitment of an extra muscle (the Flexor Digitorum Longus muscle) to help with the function of the weak muscle. Because the Flexor Digitorum Longus muscle is attached to the toes by a tendon, the constant pathological pull of the tendon may cause the toes to contract over time. But the most common reason for contracted toes (90% of biomechanical causes), is Flexor Stabilization. This is the condition where excessive pronation (from a very wide variety of potential reasons) or inability of the small stabilizing muscles of the toes (lumbricales, interossei muscles) result in the Flexor Digitorum Longus muscle to exert excessive power onto the toes, resulting in their contracture.
It's very important for the patient to know that the types of non-surgical and surgical treatments indicated for each of these conditions is quite different. So patients with contracted toes very much need to be treated by an individual very well versed in biomechanics in order for their treatment to be successful. No patient wants to have to be told to purchase expensive orthoses (orthotics) or other orthopedic appliances if they wont' work or have the wrong surgical procedure performed because the wrong cause was identified.
How can contracted toes be treated?
Many people start by treating the problem themselves when they have a painful corn or callus. They try to remove the corn by cutting it off or by applying strong acids, and they try to cushion the toe by applying cushioned pads. But because these treatments can be difficult to perform by oneself (and should never be done by oneself when the patient is diabetic or circulation is poor), and because these treatments only treat the symptom, not the structural deformity that causes their symptom, these treatments can often provide only limited success, and often any success is for only short periods of time.
Successful control of the causes of contracted toes may or may not require orthoses (it depends on the biomechanical cause of the contracted toes) and surgical correction is sometimes necessary.
What is the surgery like?
In most cases, surgery to fix toe contractures can be done in the office operating room, using local anesthetic. A small incision is made, and the deformity is corrected by one of several procedures.
- For early conditions involving no arthritis, a rebalancing of tendons may be done around the joint. Several techniques have been designed to accomplish this. These procedures may be done alone or in conjunction with one of the other procedures below.
- When arthritis has developed, a portion of abnormal bone around the joint may be removed. This would allow the toe to still be able to bend. This kind of procedure is known as a Post procedure, or an arthroplasty. Cases caused by Extensor Substitution or Flexor Stabilization may benefit from this sort of procedure.
- For severe contractures, or in cases of Extensor Substitution, for example, the abnormal toe joint may be fused.
The patient goes home in a special post-operative shoe and in most case, can walk immediately.
How do I know when it is time to consider surgery?
If you find you cannot comfortably fit in your shoes, if you get little or no relief from removing painful corns, if padding and other conservative treatments provide you no comfort, and if the condition is worsening, then you may wish to consider surgical correction. You will need to have adequate circulation and be in adequate health to proceed with the surgery.