Underlapping Toes

Underlapping Toes

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and becomes progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toes, overlapping toes, flexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.

Underlapping Toes Description
Underlapping toes are commonly seen in the adult and pediatric population. The toes most often involved are the fourth and fifth toes. A special form of underlapping toes is called clinodactyly or congenital curly toes. Clinodactyly is fairly common and follows a familiar pattern. One or more toes may be involved with toes three, four, and five of both feet being most commonly affected.

The exact cause of the deformity is unclear. A possible etiology is an imbalance in muscle strength of the small muscles of the foot. This is aggravated by a subtle abnormality in the orientation on the joints in the foot just below the ankle joint called the subtalar joint. This results in an abnormal pull of the ligaments in the toes causing them to curl. With weight-bearing, the deformity is increased and a folding or curling of the toes results in the formation of callus on the outside margin of the end of the toe. Tight-fitting shoes can aggravate the condition.

Determine Treatment
The age of the patient, the degree of deformity, and symptoms determine treatment. If symptoms are minimal, a wait and see approach is often the best bet. When treatment is indicated the degree of deformity determines the level of correction. When the deformity is flexible in nature a simple release of the tendon in the bottom of the toe will allow for straightening of the toe. If the deformity is rigid in nature then removal of a small portion of the bone in the toe may be necessary. Both of these procedures are common in the adult patient for the correction of hammertoe deformity. If skin contracture is present a derotational skin plasy may be required.

Overlapping Toes – Overlapping Fifth Toe Description
This deformity is characterized by one toe lying on top of an adjacent toe. The most common toe involved is the fifth toe. When one of the central toes is involved the second toe is most commonly affected. The etiology of the condition is not well understood. It is thought that it may be caused by the position of the fetus in the womb during development. The condition my run in families so there may be a hereditary component to the deformity.

Conservative Treatment
Effective conservative treatment depends upon how early the diagnosis is made. In infancy, passive stretching and adhesive taping is most commonly used. This may require 6 to 12 weeks to accomplish and reoccurrence is not uncommon. Rarely will the deformity correct itself? As the individual matures the deformity becomes fixed. When surgical correction is warranted a skin plasty is required to release the contracture of the skin associated with the deformity. Additionally, a tendon release and a release of the soft tissues about the joint at the base of the fifth toe may be required. In severe cases, the toe may require the placement of a pin to hold the toe in a straightened position. The pin, which exits the tip of the toe, may be left in place for up to three weeks. During this period of time, the patient must curtail their activities significantly and wear either a post-operative type shoe or a removable cast. Excessive movement at the surgical site can result in a less than desirable result. The pin can be easily removed in the doctor’s office with minimal discomfort. Following removal of the pin splinting of the toe may be required for an additional two to three weeks.

Hammertoes and Mallet Toes Description
Another common digital deformity is a contracture of the toes in the formation of hammertoes and mallet toes. Hammertoes are described in depth in another article. Mallet’s toes are a result of the contracture of the last joint in the toe. In the pediatric population, it is often flexible and not painful. Over time the deformity becomes rigid and a callus may form on the skin overlying the joint at the end of the toe. Additionally, the toenail may become thickened and deformed form the repetitive jamming of the toe while walking. The deformity usually involves one or two toes, with the second toe most commonly affected. Mallet’s toes have several etiologies. Longer toes that are forced against a short toe box in the shoe will, over time, develop a contracture of the last joint in the toe causing a mallet toe.  Cited www.podiatrynetwork.com

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