Prospective study of a noninvasive treatment for two common congenital toe abnormalities (curly/varus/underlapping toes and overlapping toes)

Two common congenital toe abnormalities (curly/ varus/underlapping and overlapping) are frequently seen in paediatricians’ offices. Current textbooks serve as a main source of reference in this setting. Neither abnormality is mentioned in one standard paediatric textbook (1) and both are mentioned in another standard textbook (2). Curly/varus/underlapping toes (flexion, laterally rotated and varus, Figure 1A) are said to correct spontaneously in 25% to 50% of cases, and surgical correction is warranted at three to four years of age. Overlapping toes (adducted, externally and laterally rotated, Figure 1B) are said to be common: nonoperative intervention is stated as ineffective and surgical correction is the current management choice (2). Figure 1 A Curly/varus/underlapping toe; B Overlapping toe A literature search (Medline 1966 to 2004) using the key words ‘curly/varus/underlapping’; ‘overlapping’; ‘toes’; and ‘congenital abnormalities’ revealed significant controversy. Trethowan (3) clearly distinguished between congenital and acquired abnormalities, indicating that congenital abnormalities were amenable to conservative treatment. That initial article defined ‘hammer toe’ as a fixed flexion deformity, but also noted that the term has been used to describe any flexion deformity. Sweetnam (4), the author of an often quoted article in which the term ‘curly toe’ was first used, used the term for toes that were adducted, flexed and curled under the neighbouring toe. Sweetnam’s study used a prospective design, examining 50 feet assessed in infancy and followed up to adolescence. None of the children had any symptoms at that age. Of those treated, 27% improved, and 25% improved with no treatment (combined total of 13 feet). This left 75% (37 feet) remaining with abnormalities (4). A number of different devices have been suggested to correct these abnormalities (5). Jordan and Caselli (6) suggested that all overlapping toes could ultimately be corrected with strapping, but that one should wait until four months of age to do so because, before this age, the technique proves difficult and inefficient. The literature has suggested that clinicians should avoid surgery in the very young (7,8). A textbook in podopaediatrics (9) has defined overlapping, underlapping and curved toes all in the same group of abnormalities, and indicates that toe taping is still a valuable technique in the newborn. An editorial (10) indicated that varus rotational deformities are frequently observed during podopaediatric examinations. Strapping was further explored in 1987 (11) in a sample of 56 children with these abnormalities, 28 of which were reviewed (50%). All children were older than five months of age at presentation. Most patients presented to that study due to concerns from their parents regarding the cosmetic appearance of their child’s foot. Of those followed, the mean duration of strapping was 13.7 months (range, one month to three years). Of this group, 14% discontinued due to discomfort and 37% did not meet the study criteria due to a lack of minimum duration of treatment (11). The grading scale of toe improvement used by Turner (11) was defined as unchanged, improved (straighter than pretreatment but still some overlap of adjacent toes) and cured (the toe matched the shape of the adjacent toes with no overlap). Children in Turner’s study complained of discomfort with footwear due to their toe abnormality at a rate of 10%. Overall, 68% improved by the end of strapping. Of the small group who received no treatment, 45% (two of five children) spontaneously corrected (less than 10% of the charts reviewed). The author hypothesized that there is little need for this intervention when the literature supports a 25% spontaneous cure with only a 50% improvement with this strapping method (11). A grading system has been described for the degree of abnormality of toes with any varus malignment (grade 0 = no deformity; grade 1 = mild curl with and without adduction, and with or without rotation; grade 2 = grade 1 plus some overriding of the adjacent toe; and grade 3 = grade 2 plus increased fixed flexion, so that the toenail was not visible from the dorsum of the foot) (12). Despite the apparent lack of significance of the abnormality, there is a plethora of articles available on the surgical procedures used to correct these abnormalities, including one article (8) that reviews 20 different surgical approaches to the problem (8,13–18). Given the conflicting literature and lack of studies in the newborn, and considering our experience with pliable soft tissue and cartilage in the newborn (19,20), we designed a study to explore a simple technique in the newborn to correct this congenital abnormality.