Hammer, claw and mallet toes: shoes, pads, toe exercises and when surgery helps

Hammer, claw or mallet?

Each smaller toe has three bones that should form a straight line. These deformities come from the toe's tendons tightening, then its joints. Papers don't use the names consistently: of 35 articles that clearly defined hammer toe, all included the bent middle joint but only about half (49%) added the lifted base, and claw toe was defined in several ways. So leaflets and surgeons may use the names a little differently. In general:

• Hammer toe: bent down at the middle joint. The base of the toe may tilt up a little and the tip lies almost flat.
• Claw toe: bent up at the base and down at the middle and end joints, so the tip digs into the sole of the shoe.
• Mallet toe: bent down at the end joint only.

Sources 1, 2, 3, 4, 5

Who gets themEmerging evidence

In 784 adults aged 65 and over in the USA, 60% had a deformity of the smaller toes. An NHS leaflet estimates that 2% to 20% of the population have hammer toes. The second toe is affected most often, and the deformities often come with a bunion. In a population study, flat feet went with higher odds of hammer toes.

Sources 6, 7, 8, 1, 4, 9

Why they happen

The muscles that bend and straighten the toes become unbalanced, and over time the tendons and joint capsules tighten. NHS and orthopaedic leaflets list shoes that are tight, short, narrow or high-heeled; a bunion; an injury; arthritis; weak foot muscles; high-arched or flat feet or stiff ankles; and weight gain and age.

Claw toes in particular can come from nerve damage, for example from diabetes, a stroke or alcohol, which weakens the small muscles of the foot. Curled toes are also a symptom of Charcot-Marie-Tooth disease, an inherited nerve condition.

Sources 2, 8, 7, 10, 4, 3, 11

Flexible or stiff, and when an X-ray helps

Early on, the toe can be straightened by hand; over time it stiffens into place. That matters, because a stiff toe won't straighten without surgery, while a flexible one can be managed with shoes and pads and, if needed, a smaller operation.

Bent toes are diagnosed by examining the foot. An NHS leaflet says an X-ray might be requested if surgery is being considered.

Sources 2, 3, 7, 8

Symptoms, and why diabetes matters

Many bent toes never hurt. When they do: pain over the bent joint from a corn, at the tip of the toe, or under the ball of the foot; redness and thick skin where shoes rub; difficulty finding shoes; and occasionally an ulcer at a pressure point.

With diabetes and numb feet, a corn or blister over a bent toe can turn into an ulcer without you noticing. NICE (the National Institute for Health and Care Excellence) counts a foot deformity as a risk factor for diabetic foot problems, and in a trial in people with diabetes, releasing the tendon that bends the toe lowered the pressure on its tip.

Sources 7, 1, 10, 12, 13

If it doesn't hurt, it needs no treatmentEmerging evidence

NHS orthopaedic leaflets say treatment is not recommended if the foot isn't painful, and that surgery is only for pain that other measures can't control. This is clinical consensus rather than trial evidence.

Sources 8, 7

Shoes and padding come firstStrong evidence

A 2018 review calls care without surgery, meaning proper shoes, orthoses and inserts with targeted physiotherapy, the first-line treatment, which can often avoid surgery. The advice is consistent: shoes about half an inch (just over 1 cm) longer than your longest toe, with a soft, deep, roomy toe box and a low heel; in-depth shoes with extra room in the toe box for a claw toe; and a stiff or rocker sole if the ball of the foot hurts.

Pads, silicone toe sleeves and props take pressure off corns and the toe tip. In pressure studies, a pad placed just behind the ball of the second toe cut peak pressure by 33%, and a custom silicone prop under a bent second toe lowered the pressure on its tip in 20 older adults. A review notes that none of these is a permanent solution to the deformity, and none has been tested against no treatment for pain in a large trial.

Sources 14, 2, 3, 10, 1, 15, 16, 17

Splints and straighteners: comfort, not a cureEmerging evidence

For an early, flexible claw toe, the American Academy of Orthopaedic Surgeons (AAOS) suggests a splint or tape to hold the toes straight. In a small trial of 36 people with claw or hammer toes and pain under the ball of the foot, an adjustable toe splint worn for 2 weeks, with shoe advice, eased pain more than shoe advice alone. No study shows that splints or straighteners straighten a toe for good.

Sources 3, 18, 16

Toe exercises: widely advised, untested as a treatmentMixed evidence

Orthopaedic and NHS leaflets advise stretching the toes straight by hand, picking up marbles with the toes, towel curls, toe spreading and toe lifting, while the toe is still flexible. No trial has tested toe exercises as a treatment for hammer, claw or mallet toes.

There is indirect support. A 12-week toe strength programme raised toe strength by up to 36% in older people, and in 312 older people followed for a year, those with weaker toes and toe deformities were more likely to fall. So toe exercises may help strength and balance, but they won't straighten a stiff toe.

Sources 2, 3, 10, 19, 20

Surgery: for pain, not looksEmerging evidence

Surgery is for pain that shoes, pads and podiatry can't control, and an NHS leaflet says you should not consider it for cosmetic reasons. For a flexible toe, surgeons may release or lengthen a tendon, or move the tendon that bends the toe to the top of it. For a stiff toe, they usually remove part of the middle joint and fuse it, held with a wire for 4 to 8 weeks. A bunion is often corrected at the same time.

In two small trials (55 and 37 people), removing the middle joint gave the same pain and function as fusing it, though fusion kept the toe straighter. In a trial of 100 people, minimally invasive surgery matched open surgery for correction and function at 18 months, with fewer wound problems; 7 of the 95 people followed up were dissatisfied. In one series of 118 toes, pain improved in 92% and 84% of people were satisfied.

Recovery takes months. You walk in a special shoe straight away, swelling lasts 2 to 4 months, and a straight, stiff toe is expected. Desk work is often possible after 2 to 3 weeks and physical work after about 6 weeks or more, sport usually resumes at 3 to 6 months, and full recovery can take more than 6 months, occasionally a year. Risks include infection (deep infection in under 1%), numbness, stiffness, swelling, the bones not joining (painful in about 1 in 100), the toe bending again and blood clots, and smokers are about 4 times more likely to have bones that don't join.

Sources 8, 1, 7, 2, 4, 21, 22, 23

Diabetes and bent toes: NICE risk levelsStrong evidence

NICE asks for everyone with diabetes to have their feet checked when diabetes is diagnosed and at least once a year. A foot deformity on its own counts as moderate risk, and a deformity with nerve damage (neuropathy) or narrowed leg arteries counts as high risk, as does any previous ulcer or amputation. Moderate and high risk mean referral to a foot protection service, which NICE asks to see you within 6 to 8 weeks (moderate) or 2 to 4 weeks (high) and to check your feet every 3 to 6 months or every 1 to 2 months.

The NHS says not to treat corns or calluses yourself if you have diabetes, and to see a GP or diabetes nurse about blisters or cracked skin on your feet.

Sources 12, 15, 24

A tendon release for toe ulcers in diabetesEmerging evidence

The International Working Group on the Diabetic Foot's 2023 guideline suggests considering a release of the tendon that bends the toe (a flexor tenotomy) for a flexible hammer toe with a sore that is about to break down. In a Danish trial of 95 people with diabetes, a needle tenotomy healed all 8 toe ulcers against 3 of 8 with usual care, and of 79 people with an ulcer about to form, 1 went on to an ulcer against 7 with usual care, with no serious side effects. It also lowered the pressure under the toe.

Sources 25, 26, 13

Shoes that make room

Choose shoes about half an inch (just over 1 cm) longer than your longest toe, which for many people is the second toe, with a soft, deep, roomy toe box and a low heel. For a stiff claw toe, in-depth shoes with extra room in the toe box help, and a shoe repairer may be able to stretch a pocket in the toe box over the bent toe. A stiff or rocker sole can ease pain under the ball of the foot.

Sources 2, 3, 10, 1

Pads, sleeves and podiatry

Non-medicated corn pads, cushions, silicone toe sleeves and toe separators from a pharmacy take pressure off, and insoles with support under the ball of the foot help if it aches. Don't cut corns yourself: a podiatrist can trim them and supply pads and insoles, and in many areas you can refer yourself. If you have diabetes, poor circulation or numb feet, talk to your GP or podiatrist before treating your feet yourself.

Sources 15, 10, 2, 7

Toe exercises the figure can't show

Toe movements this small can't be shown on the 3D figure, so here are written steps. They're worth trying while a toe is still flexible; they won't straighten a stiff one. The toe spreading dose comes from an NHS podiatry leaflet, which also shows toe lifting; the counts for stretching by hand are editorial.

• Straighten the toe by hand: sit with the foot resting across the other knee, hold the bent toe at its base, and gently ease the bent joint straight. Hold for 20 to 30 seconds, 3 to 5 times a day, and stop if it hurts.
• Spread the toes: loop a light band round the toes and spread them apart against it. Keep going until the toes tire, or for 1 minute, 5 times, 3 days a week.
• Pick up small objects, such as marbles, with your toes and drop them into a bowl.

Sources 2, 3, 10

With diabetes or numb feet

Check your feet every day, including between the toes and over the bent joints, and get any wound, blister or colour change seen the same day. Ask your diabetes team which risk level you're in and how often your feet should be checked. Wear shoes that fit the bent toes rather than squashing them. The international diabetic foot guideline also advises treating any sign of a sore promptly, and not walking without suitable footwear.

Sources 12, 15, 25