Fifth Toe

Over-riding Fifth Toe




5th toe adducted & overrides 4th toe

- extended, adducted & laterally rotated at MTPJ




Toe arises more dorsally than it should


Contracture of EDL tendon

Contracted dorsal skin & dorsal MTPJ capsule




Usually congenital deformity

- toe usually hypoplastic


Clinical Features


Cosmetic deformity

Problems with footwear

Usually bilateral

Usually needs surgery (compared with underriding or curly)


Non-operative Management


Strapping & taping ineffective

Broad toe box


Operative Management


Mild / Moderate - Butler procedure 

- racquet shaped incision dorsally

- dorsal limb over extensor tendon

- circumferential limb must preserve NV bundle

- EDL and dorsal capsule divided

- toe swung back into position and sutured


Severe - Lapidus procedure 

- EDL transfer to AbDM

- curvilinear incision

- cut EDL over mid MT proximally leaving attached distally

- capsule release MTPJ

- tendon transferred medial, plantar and laterally around P1

- sutured to abductor digit minimi


Underriding fifth toe


Opposite deformity of above


Thompson excisional arthroplasty

- Z incision laterally over P1

- proximal phalanx resection and capsule imbrication

- K wire


Cock Up Deformity 



- of MTP 

- realign at MTPJ & IPJ

- usually hammer toe deformity as well


Surgical Algorithm


Mild to moderate 

- extensor tenotomy & fixed hammer toe repair



- Ruiz-Mora procedure

- resection arthroplasty of proximal phalanx

- elliptical plantar incision with proximal phalyngectomy



- end up with floppy toe 

- syndactylisation may be salvage

- but swapping one deformity for another