Forefoot Deformities

The forefoot can develop several deformities that can cause pain, functional problems, and deformities of other toes. Thick calluses form over points where the deformed area presses into the shoe, and they can ulcerate and become infected in severe cases. Proper treatment helps relieve the pressure points and your pain.

Often the great toe angles away from the bunion and presses against the small toes. This condition is called hallux valgus and can cause deformities in the small toes too. Some people have a greater tendency than others to develop bunions and hallux valgus. Wearing shoes with heels and narrow toe boxes is a major cause of these deformities. Thus, women have 10 times the risk that men have for these problems.

Small toe deformities
The small toes generally can form two types of deformities: hammer and mallet contractures (Fig. 2). These conditions most often affect the second toe because it usually is the longest and is forced into the tip of the shoe. Hammer toe means that the toe contracts all of its joints and curls upward. The curling creates pressure on the tip of the toe, on the top of its middle joint, and under the ball of the foot. The pressure produces severe pain at these points. Mallet toe causes just the tip of the toe to contract and causes pressure on this area. Again, wearing tight, short shoes adds to the pressures that cause and aggravate small toe deformities.

Nonoperative treatment
Nonoperative treatment for these conditions focuses on relieving the pressure points. Wearing properly fitted shoes with toe boxes that allow toes to move freely can alleviate much pressure. Your shoes should have heels that are no higher than two inches and should have toe boxes that are no more than one-fourth inch narrower than the widest part of your forefoot. Special pads that you can purchase at the local pharmacy relieve pressure points on the ball of the foot and on the toes. However, these devices do not correct the deformities.

Operative treatment
If you have extreme or disabling pain, you may need surgery to correct the deformity and, thus, permanently resolve the pressure problems. Surgery involves shaving or cutting the bone and adjusting the ligaments (tissues that connect two bones) of the affected toe. Recovery takes time.

To correct the bunion deformity, the surgeon removes the bulging portion of the bone and tightens the toe's ligaments (Fig. 3). Sometimes, he or she needs to realign the midfoot bone (below the toe) to correct more severe deformities. This procedure involves cutting the bone and stabilizing it with pins and screws.

The surgeon corrects small toe deformities by cutting out bony portions of the affected toe, loosening the ligaments, and putting in a temporary pin to allow the toe to heal straight.

To enable the foot to heal properly after surgery, you must wear protective shoes and splints and use crutches while continuing your daily activities. In two to three months, you can wear regular shoes, but you may have some soreness for several more months until the foot and toes completely heal.

Forefoot deformities cause severe pain or disability that may need to be treated with surgery. Remember, to prevent deformities, ensure that you wear low-heeled, properly fitted shoes that have wide toe boxes.

Stephen C. Hunter, M.D.
Columbus, Georgia

Further reading:
1. American Orthopaedic Foot and Ankle Society. The adult foot. http://www.aofas.org/adultfoot.html To order a hard copy of the brochure, send a self-addressed, stamped envelope to: AOFAS, 1216 Pine Street, Suite 201, Seattle, WA 98101. Specify the name of the brochure.
2. American Academy of Orthopaedic Surgeons. Common foot problems. http://www.aaos.org/wordhtml/pat_educ/commfoot.htm For a hard copy, send a self-addressed, stamped envelope to: AAOS, 6300 North River Road, Rosemont, IL 60018-4262. Specify the name of the brochure.