Foot Ankle iSAWE 18

Question

A 70 year old woman has painful callosities over the dorsum of her toes and under the metatarsal heads.

Foot Ankle iSAWE 18, clinical photograph of the feet
Clinical photograph of the feet. Image by Wwcmdmsha at neurosigns.org, Wikimedia Commons, CC BY-SA 4.0.
  1. Describe the deformities shown.
  2. Explain the pathomechanics.
  3. Outline management.

Answer

Deformities

DeformityMTPPIPDIP
Hammer toeExtended or neutralFlexedExtended or neutral
Claw toeHyperextendedFlexedFlexed
Mallet toeNeutralNeutralFlexed
  • Assess whether flexible or fixed
  • Look for an underlying neurological cause if multiple and bilateral

Pathomechanics

  • Intrinsic minus imbalance, extrinsic extensors overpower weak intrinsics
  • Tight footwear and hallux valgus crowd the second toe
  • Plantar plate attenuation causes MTP subluxation
  • Neuromuscular causes, CMT, diabetes, rheumatoid arthritis

Management

  • Wide deep toe box shoes, toe sleeves and padding
  • Flexible deformity, flexor to extensor transfer (Girdlestone-Taylor)
  • Fixed PIP deformity, PIP resection arthroplasty or fusion
  • MTP extension contracture, extensor tenotomy, capsulotomy and plantar plate repair
  • Weil osteotomy for dislocated MTP joints
  • Correct hallux valgus at the same time

Related pages

Author Contributions

Orthofracs team

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.