Lesser Toe Problems – Advice for Referrers

Referral is usually only necessary if any of the following are present:

• A fixed toe deformity resulting in pain, nail irritation or blistering
• Extra toes
• Syndactyly - refer to plastic surgery if referral requested

Many children have toes that overlap or under-ride each other and the vast majority never cause any problem. Most lesser toe deformities will resolve as the child gets older and their toes grow.

Even if they do not fully resolve, it is unusual for minor persistent toe deformity to cause problems in adulthood.

There is very little Paediatric Orthopaedics can do about most lesser toe deformities as our surgical options are limited to tenotomy and soft tissue correction which can be harmful if the toe has normal mobility already. It can be helpful to demonstrate to the parents that the toes can passively be positioned normally and suggest that this indicates the toes won’t be problematic.

We would never fuse a toe in a child as it would halt growth and cause more problems. There is no role for operating on an asymptomatic toe in childhood to try and prevent toe problems in adulthood which are unlikely to occur. If blistering or corn formation is starting then toe cushions and wide toed shoes should be tried first. Only if these fail due to persistent, fixed deformity would we consider tenotomy for fixed deformity.

Curly third and fourth toes

This is very common. It is due to a minor imbalance of the small muscles in the foot. These toes rarely cause problems even though they tend to sit under the next toe. Curly toes are never the reason for late walking in a child.

If the toe causes no pain there is no need for treatment. Strapping the toe or toe spacers do not correct the toe shape. Indication for intervention are pain, skin or nail breakdown. In those instances only will a flexor tenotomy be considered. This will straighten the toe to stop the child walking on their nail but the shape will remain curly. If toe shape is the only problem the risks of surgery are probably too high

Over-riding second toe

An over-riding second toe is where the second toe lies cocked up above the first and third toes. This is usually found in the smaller, slightly fatter foot of a baby or an infant. The foot as it grows will become thinner, and as it begins to take the weight of the body it spreads wider. The toe usually then comes to lie in line with the others. Treatment with strapping has no benefit and is not needed for something that will get better with growth.

Webbed toes

Webbing between the second and third toes is common. It never causes symptoms even if complete and attempts to separate the toes with surgery can cause major problems with skin healing and

infections. The fear that the child will be teased rarely occurs because children seldom go far with bare feet. The webbing is not easy to see in an active child.

Over-riding fifth toes

In this condition the fifth toe lies on top of the fourth toe. Sometimes it looks quite striking but often is not troubling. If there is pain, or the parents are unable to find footwear that does not rub then treatment may be required. Strapping or splints do not seem to help so surgery may be considered. However there can be complications of such surgery and therefore it reserved for when the toe is causing significant problems.

In the adolescent bunions may begin to develop. There is usually a family history of hallux valgus when presenting as an adolescent. It is much more common in females. Shoes are important. Fashion shoes with pointed toes are especially harmful. Parent should be advised that any wide based shoe that fits well, including trainers and sandals, are perfectly OK. There is no treatment, other than wearing shoes that fit and possibly barefoot walking, which can prevent hallux valgus from developing. Surgery may eventually become necessary for severe cases. Surgical correction is best left till adulthood since the bunions tend to recur rapidly if the foot is still growing.

Other toe problems

There are several other variations of toes that can cause anxiety. The big toe can be hooked inwards (called metatarsus adductus), curled (called hallux flexus) or pointing upwards (called hallux erectus). Metatarsus adductus has all but disappeared since we stopped lying babies face down in the cot. Some children will actively hook their big toe inwards when standing in bare feet but the toe lies normally in the shoe. They always grow out of it so no treatment is needed. It is the same for hallux flexus and hallux erectus which always disappear in time.