Lesser Toes Deformities

Position of proximal phalanx in MTP joint is determined by the balance between EDL and antagonistic pull of intrinsic muscles
Position of middle and distal phalanges at IP joints is determined by pull of FDL and FDB
Imbalance between extrinsic and intrinsic muscle pull is the basis of toe deformities
Often there is a positive family history
Female > Male

Poor fitting shoe
Neuromuscular imbalance
- Poliomyelitis
- Peroneal muscle atrophy
- Freidrich’s ataxia
- Idiopathic pes cavus
- Myelopathy
- Radicular neuropathy
- CP
- MS
Volkmann contracture
Arthritis
- RA
- Psoriasis
Whenever the deformity involves an isolated toe (usually 2^nd toe), external pressure (shoe), trauma or arthritis should be considered
Often all toes are involved, in which case an underlying neuromuscular condition should be considered

Pain and callus in pressure areas in contact with footwear
Plantar pain in the area of metatarsal heads
Perform the examination both in standing and sitting positions
Look for callosities in
- Webs
- Dorsal aspect of PIP : Claw toe, Hammer toe
- Dorsal aspect of DIP : Mallet toe
- Toe-tip : Mallet toe
Joint dislocation/subluxation
ROM : the joints are mobile initially, but become rigid gradually
Push up test : determines flexibility of the deformity. Keep the ankle in neutral position, put fingers beneath metatarsal head and push dorsal ward; see if the deformity corrects
Check neurovascular status
Check for signs of arthritis

Primary deformity is hyperextension of the metatarso-phalangeal joints (intrinsic minus deformity), due to contracture of extensor tendons
Associated with flexion of the IP joints
Overtime, plantar plate fails, proximal phalanx subluxes dorsally and plantar fat pad migrates distally; consequently :
- Transfer metatarsalgia develops
- Callosities develop under the metatarsal heads or over the interphalangeal joints

Non operative treatment

Operative Treatment

Flexible deformity:
- Flexor to extensor tendon transfer
- Capsular release, EDB tenotomy plus EDL lengthening
Fixed deformity:
- MTP deformity:
  - Begin with MTP capsular release and extensor tendon lengthening
  - If deformity still persists, proceed to Weil osteotomy (metatarsal shortening)
- PIP deformity
  - Resection arthroplasty of DuVris
  - Interphalangeal arthrodesis in severe or recurrent cases
Complications
- Ischemia secondary to stretching of the neurovascular structures
- Recurrent deformity
- Incomplete correction

Primary deformity is PIP flexion
Metatarso-phalangeal and DIP joints are usually extended
The second toe of one or both feet are commonly affected
Hyperextension of the MTP joint may cause subluxation/ dislocation with subsequent painful callosities under the metatarsal heads and over the IP joints

Aetiology

Long toe, short shoe
Similar to the Boutonniere deformity of the hand and may be related to extensor mechanism failure

Nonoperative treatment

Operative treatment

Flexible deformity:
- Split FDL transfer to extensor hood at proximal phalanx
- FDL tendon will now plantar flex MTP joint and extend IP joints
Rigid deformity:
- PIP deformity
  - Resection arthroplasty with or without FDL tenotomy
  - Arthrodesis with or without FDL tenotomy
- MTP deformity
  - Capsular release, EDB tenotomy and EDL lengthening
  - If deformity persists Weil procedure (metatarsal shortening osteotomy) or DuVris procedure (resection of distal head of proximal phalanx) may be necessary

Nonoperative treatment

Operative Treatment

Flexible deformity: Percutaneous FDL tenotomy at level of distal flexion crease
Rigid deformity:
- Resection arthroplasty (condylectomy of middle phalanx)
- DIP arthrodesis with or without FDL tenotomy