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Disorders of the lesser toes

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The lumbricals originate from the metatarsals flex the MTP joint and extend the PIP and DIP joints.


Claw toes are caused by an imbalance between the extrinsic foot muscles, originating from the lower leg, and the intrinsic muscles in the foot, causing flexion at the PIP (proximal interphalangeal) joint and extension at the MTP (metatarsal phalangeal) joint. The PIP joints become prominent and can be irritated by shoes, leading to painful calluses on the dorsal aspect of the toes (Figure 3).


  • diabetes, with peripheral neuropathy
  • rheumatoid arthritis 
  • primary neuromuscular disease (poliomyelitis,  Freidrich's ataxia, myelopathy, multiple sclerosis or Charcot Marie Tooth Disease  
  • other foot deformities such as bunions, flat feet, or pes cavus deformity (highly arched feet)

Red flags

All lesser toes deformities are red flag findings, suggesting the presence of a complication of diabetes or a neurological disorder. Close evaluation of the whole patient is essential.

Treatment options and outcomes


Foot surgery, in general, is more susceptible to wound complications; toe deformity surgery, in particular, can be complicated by recurence recurrence of the deformity.

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