Lesser Toe Problems

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EXPERT PATIENT GUIDE · LONDON & NORTH LONDON

Toe Deformities

Claw Toe · Hammer Toe · Mallet Toe · Crossover Toe

A comprehensive patient guide by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, Royal National Orthopaedic Hospital (RNOH) Stanmore and UCL — London, UK.

At a Glance: Toe Deformities

Conditions	Claw toe, hammer toe, mallet toe and crossover toe — bending, curling or drifting of the lesser (smaller) toes.
How Common	Very common. In national forefoot-surgery data, close to 1 in 4 patients need a lesser-toe procedure.
Most Common Causes	Tight or high-heeled footwear, bunions (hallux valgus), inflammatory arthritis, diabetes, nerve or muscle imbalance.
Key Distinction	Whether the toe is still flexible (correctable by hand) or fixed (stiff) — this guides treatment.
Diagnosis	Clinical examination, weight-bearing X-ray, and ultrasound or MRI where a plantar plate tear is suspected.
Non-Surgical Care	Wider deep toe-box shoes, silicone toe sleeves and pads, offloading insoles, taping and targeted injections.
Surgical Options	Soft-tissue releases, tendon transfers, Weil osteotomy, joint fusion or excision, plantar plate repair, keyhole (MIS) surgery.
Specialist	Mr Matthew Welck — Consultant Foot & Ankle Surgeon, RNOH Stanmore & UCL, London & North London.

What Are Toe Deformities?

Toe deformities are changes in the shape and position of the smaller toes (the four toes next to the big toe, known as the lesser toes). Each of these toes has three small bones and three joints. When the delicate balance between the tendons that bend the toe and those that straighten it is upset, a toe can curl, buckle or drift out of line.

The four most common deformities are claw toe, hammer toe, mallet toe and crossover toe. They differ in which joint is affected and in which direction the toe points, but they often overlap and more than one can be present in the same foot. Left untreated, a toe that is flexible at first can gradually become stiff and fixed.

Because these deformities can rub in shoes, cause pain in the ball of the foot and affect how you walk, early assessment by a Consultant Foot & Ankle Surgeon — such as Mr Matthew Welck in London and North London — gives you the widest range of treatment options. Learn more at matthewwelck.com.

How Common Are They in the UK?

Lesser toe deformities are among the most frequently treated foot problems. National forefoot-surgery data show that close to a quarter of patients undergoing forefoot surgery have a lesser-toe procedure as part of their operation.

They become more common with age and are seen more often in women, partly reflecting a lifetime of narrow or high-heeled footwear. Hammer toe and crossover toe most often affect the second toe, and crossover toe in particular is typically seen in women over the age of 50, frequently alongside a bunion.

What Causes Toe Deformities?

Toe deformities usually develop gradually. Common contributing factors include:

Footwear — narrow, pointed or high-heeled shoes that crowd and bend the toes over many years.
Bunions (hallux valgus) — a drifting big toe crowds the lesser toes and overloads them, making deformity more likely.
Inflammatory arthritis — such as rheumatoid arthritis, which weakens the small joints and their supporting tissues.
Plantar plate injury — wear or tearing of the strong pad beneath the knuckle joint, which normally keeps the toe stable and straight.
Nerve and muscle conditions — neuromuscular disorders and a high-arched (cavus) foot can pull the toes into a claw position.
Diabetes and nerve problems — altered sensation and muscle balance can accelerate deformity and increase the risk of skin problems.
Toe length — a relatively long metatarsal or toe can be placed under greater pressure and buckle over time.

What Are the Symptoms?

Symptoms vary with the type and severity of deformity, but commonly include:

A visibly bent, curled or drifting toe
Corns and hard skin (callosities) on top of the toe, at the tip, or under the ball of the foot
Pain in the ball of the foot (metatarsalgia), especially on walking or standing
Rubbing, blistering or ulceration against footwear
Difficulty finding comfortable shoes
A feeling that the toe is unstable or ‘giving way’, particularly with crossover toe

In the early stages the toe can often still be straightened by hand (flexible). Over time the joint stiffens and stays bent (fixed). This distinction is important because it strongly influences which treatments are likely to work.

Investigations

Most toe deformities are diagnosed from the history and a careful examination. Mr Welck will assess:

Flexibility — whether each deformity is still correctable by hand or has become fixed.
Joint stability — gentle tests (such as the drawer or Lachman test) check the knuckle joint for looseness that points to a plantar plate tear.
The whole foot — bunions, arch shape and any hindfoot problems that may be driving the deformity.

Imaging and tests

Weight-bearing X-rays — the first-line test, showing alignment and the length of the toe bones while you stand.
Ultrasound or MRI — useful to confirm a suspected plantar plate tear or to look for other soft-tissue problems.
Blood tests — if inflammatory arthritis, gout or diabetes is suspected.

Claw Toe

In brief: The knuckle joint bends up while both joints further down the toe bend down — giving a claw-like shape.

What it is

In a claw toe the toe is hyperextended (bent upwards) at the knuckle joint where it meets the foot, and bent downwards at both of the joints further along the toe. The tip is often pulled back so that the toe grips like a claw. Claw toes frequently affect several toes at once and are commonly linked to a high-arched foot or an underlying nerve or muscle condition.

Symptoms

Corns on top of the bent joints and at the tip of the toe
Pain and callosity under the ball of the foot as the toe lifts off the ground
Rubbing against the top of the shoe

Treatment

Flexible claw toes may respond to roomier footwear, padding and offloading insoles, and to soft-tissue surgery such as a tendon release or a flexor-to-extensor tendon transfer that rebalances the toe. Fixed claw toes usually need a small joint procedure, and any instability of the knuckle joint is corrected first.

Hammer Toe

In brief: The middle joint of the toe buckles upward into a peak, most often affecting the second toe.

What it is

A hammer toe is bent downwards at the middle joint so that the toe rises into a peak, like a hammer. The knuckle joint may be normal or bent upwards. It is the most familiar lesser-toe deformity, is often associated with a bunion or inflammatory arthritis, and most commonly affects the second toe.

Symptoms

A painful corn over the raised middle joint
Rubbing and skin irritation in shoes
Pain in the ball of the foot if the knuckle joint becomes unstable

Treatment

Flexible hammer toes are treated first with footwear changes, toe sleeves and padding, and can be corrected surgically with a soft-tissue release or tendon transfer. When the toe has become fixed, the prominent joint is straightened by removing or fusing a small amount of bone. If the knuckle joint is also unstable, that is addressed at the same time.

Mallet Toe

In brief: Only the joint nearest the tip of the toe bends down, pressing the tip into the ground.

What it is

A mallet toe is bent only at the joint closest to the toenail, so the very tip of the toe curls down and presses into the ground or the sole of the shoe. It is often related to tight footwear and to tightness in the deep flexor tendon that bends the toe.

Symptoms

A corn or callus at the tip of the toe
Pressure and changes affecting the toenail
Discomfort when standing or walking

Treatment

A flexible mallet toe caused by a tight tendon can often be corrected with a simple keyhole release of that tendon. A fixed mallet toe is treated by straightening or fusing the small end joint, occasionally using a fine wire or a small implant while it heals.

Crossover Toe

In brief: The toe drifts sideways — usually the second toe moving towards or over the big toe — because of an unstable knuckle joint.

What it is

A crossover toe drifts out of line sideways, most often the second toe moving towards and sometimes riding over the big toe. It is usually caused by a tear of the plantar plate and stretching of the supporting ligaments on one side of the knuckle joint, which makes the joint unstable. It is most common in women over 50 and in people with a bunion.

Symptoms

A toe that is visibly deviating or overlapping its neighbour
Pain and swelling under the knuckle joint (a sign of plantar plate strain)
A sense that the toe is unstable

Treatment

Caught early while still flexible, a crossover toe may be helped by taping and offloading. Surgery is tailored to the cause and can include a plantar plate repair, a tendon transfer, a Weil osteotomy to shorten and realign the toe, and occasionally a small osteotomy of the toe bone. As a rule, the unstable knuckle joint is corrected before any smaller deformity further down the toe.

Non-Surgical Treatment

Many patients improve with simple measures, and these are always tried first:

Footwear modification — wider shoes with a deep, soft toe box to reduce pressure and slow progression.
Toe sleeves and silicone pads — to cushion corns over the joints and at the tip of the toe.
Offloading insoles — metatarsal bars or custom insoles that relieve pressure under the ball of the foot.
Taping — for a flexible, reducible toe with an early plantar plate problem.
Injections — an ultrasound-guided steroid injection can settle inflammation of the knuckle joint (capsulitis) in selected cases.
Activity and skin care — particularly important for anyone with diabetes or reduced sensation.

Surgical Options

When non-surgical measures no longer control symptoms, surgery aims to straighten the toe, rebalance the tendons and stabilise the knuckle joint so the correction lasts. The right operation is highly individualised and often combines more than one of the following techniques.

Soft-Tissue Procedures (Often for Flexible Toes)

Tendon release or lengthening — relaxing tight tendons and the joint capsule to let the toe sit straight.
Flexor-to-extensor tendon transfer — re-routing a tendon to actively hold a flexible toe in a corrected position.

Bone and Joint Procedures (Often for Fixed Toes)

PIPJ excision or fusion — straightening a fixed hammer or claw toe by trimming or fusing the buckled middle joint.
DIPJ correction — straightening or fusing the end joint for a fixed mallet toe.
Weil osteotomy — a precise shortening of the metatarsal bone that offloads the ball of the foot and helps a dislocated knuckle joint settle back into place.
Plantar plate repair — reconstructing the torn pad beneath the joint to restore stability, especially in crossover toe.

Minimally Invasive (Keyhole) Surgery

Selected procedures — such as a percutaneous flexor tenotomy or a keyhole metatarsal osteotomy (DMMO) — can be carried out through tiny incisions, with the aim of less soft-tissue disturbance and a quicker recovery. Mr Welck will advise whether a keyhole approach is suitable for you.

A guiding principle: problems at the knuckle joint are corrected before deformities further down the toe, as this gives the most reliable, long-lasting result.

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore — the UK’s leading orthopaedic hospital — and Honorary Associate Clinical Professor at UCL. He is widely regarded as one of the top foot and ankle surgeons practising across London and North London.

His NHS and private practice is dedicated entirely to the foot and ankle. Alongside the full range of lesser-toe and forefoot surgery, his specialist interests include sports foot and ankle injuries, Achilles tendon problems including Achilles tears, complex reconstruction, and total ankle replacement — so toe deformities are assessed in the context of the whole foot, not in isolation.

He has authored over 50 peer-reviewed publications, holds double fellowship training including international experience, and is a course director for national foot and ankle teaching. Patients are seen across North and Central London with rapid access to X-ray, ultrasound, MRI and weight-bearing CT.

Every option is discussed openly and a bespoke, individualised plan is agreed together. To learn more, visit matthewwelck.com.

Frequently Asked Questions

What is the difference between a hammer toe, a claw toe and a mallet toe?

They differ by which joints bend. A mallet toe bends only at the joint nearest the nail; a hammer toe bends at the middle joint; and a claw toe bends at the knuckle joint and both toe joints, giving a claw shape. A crossover toe, by contrast, drifts sideways.

Will my toe deformity get worse over time?

It can. Many toes that are flexible at first gradually stiffen and become fixed, and an unstable knuckle joint can allow a toe to drift or dislocate. Early assessment gives you more, and simpler, treatment options.

Can toe deformities be corrected without surgery?

Non-surgical measures — roomier footwear, toe sleeves, offloading insoles, taping and injections — often control symptoms very well, particularly while a toe is still flexible. They do not straighten a fixed toe, but they can keep you comfortable and slow progression.

What is recovery from toe surgery like?

Most lesser-toe surgery is a day case. You can usually walk in a supportive post-operative shoe soon afterwards, with swelling settling over several weeks to a few months. Mr Welck will give you a recovery plan tailored to your specific procedure.

Will the deformity come back after surgery?

Modern techniques that rebalance the tendons and stabilise the knuckle joint give durable results. Correcting any underlying cause — such as a bunion or an unstable joint — reduces the chance of recurrence.

Do you also treat sports injuries, Achilles problems and ankle arthritis?

Yes. As a specialist foot and ankle surgeon in London and North London, Mr Welck treats the full range of conditions, including sports foot and ankle injuries, Achilles tendon tears, and ankle arthritis requiring total ankle replacement, as well as toe deformities.

Can I be treated on the NHS?

Yes. Mr Welck treats NHS patients at the Royal National Orthopaedic Hospital and private patients across London and North London.

Where can I see Mr Matthew Welck for toe deformity treatment in London?

Mr Welck consults across North and Central London. Private appointments can be booked on 07547 395270 or by emailing secretary@matthewwelck.com. NHS patients are seen at the RNOH Stanmore.

Book a Consultation

If a bent, curling or drifting toe is causing pain, rubbing in shoes or difficulty walking, specialist assessment can make a real difference to your comfort and your long-term result.

Book a private or NHS consultation with Mr Matthew Welck, Consultant Foot & Ankle Surgeon. Early expert review gives you the widest range of treatment options.

This guide is for general information and does not replace individual medical advice. Please seek a personal assessment for diagnosis and treatment.

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Written by: Matthew Welck | Consultant Orthopaedic Foot & Ankle Surgeon London — last updated 9 July 2026