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Hammertoe
What is hammertoe?
Hammertoe is a condition in which the toes of your feet become contracted into an upside-down "V" shape, causing pain, pressure and, often, corns and calluses. Hammertoe can develop on any of the toes, but generally affects the middle three toes, most often the second toe.
The bones, muscles, ligaments and tendons of your feet normally are well-balanced to distribute your body's weight while standing, walking and running. When the first and second joints of your toes experience the prolonged stress that develops when the muscles that control them fail to work together properly, the pressure on the tendons that support them can lead to the curling or contraction known as hammertoe.
Hammertoe affects both joints of a toe — causing the toe to bend upwards at the proximal joint (the joint closest to the foot) and down at the distal joint (the one farthest away from the foot). The resulting unnatural bend is often compared to an upside down "V" and also to a hammer or a claw (The condition is sometimes referred to as clawtoe or clawfoot). A similar condition, in which the first joint of a toe simply bends downward, is called mallet toe.
Since the arched bending of hammertoe often causes the toe to rub against the top of the shoe's toe box and against the sole, painful corns and calluses develop on the toes.
Hammertoe can also be a result of squeezing within a too-small or ill-fitting shoe or wearing high heels that jam your toes into a tight toe box inside your shoe, arthritis, trauma and muscle and nerve damage from diseases such as diabetes.
Probably because of the tight-shoe and high-heel shoe factors, hammertoe tends to occur far more often in women than in men.
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How do the feet work?
Each of your feet has 26 bones, more than 30 muscles and numerous tendons and ligaments that work together to bear and propel your body weight during standing, walking and running. Bones provide support, ligaments provide stability and muscles and tendons provide movement.
The toes (as well as the fingers) are each made up of bones called phalanges, two in the big toes and three in the others. The bones at the ends are called the distal (meaning farthest away) phalanges, the ones in the middle (not present in the big toes) are called the middle phalanges, and the ones closest to the other bones of the feet are called the proximal (or nearest) phalanges. These join directly to the metatarsal bones, which lead to the bones that make up the ankles.
As you walk, the joints that connect these bones, held together by muscles, ligaments and tendons, flex each time you take a step. You place 1½ times your weight on your feet when you walk normally (and more when you run) and it's estimated that the average person walks for approximately 1,000 miles each year. When unusual stress is applied to these tissues over a period of years, the joints and tendons of your foot can cease to function in a balanced manner and toes, in an effort to compensate, can begin to bend into the hammertoe shape.
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What causes hammertoes?
Essentially, hammertoes are caused by an abnormal interworking of the bones, muscles, ligaments and tendons that comprise your feet. When muscles fail to work in a balanced manner, the toe joints can bend to form the hammertoe shape. If they remain in this position for an extended period, the muscles and tendons supporting them tighten and remain in that position.
A common factor in development of hammertoe is wearing shoes that squeeze the toes or high heels that jam the toes into the front of the shoe. Most likely due to these factors, hammertoe occurs much more frequently in women than in men.
Other causes or factors in the development of hammertoes can include an injury such as badly stubbing your toe, arthritis and nerve and muscle damage from diseases such as diabetes. And, hammertoes tend to run in families, although it is more likely the faulty foot mechanics that lead to hammertoes that are inherited, not the hammertoes themselves.
Hammertoe generally affect the smaller toes of the foot, especially the second toe, which for many people is the longest toe. It's uncommon for the big toe to be bent this way.
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What are the symptoms of hammertoe?
The most obvious symptom of hammertoe is the bent, hammer-like or claw-like appearance of one or more of your toes. Typically, the proximal joint of a toe will be bending upward and the distal joint will be bending downward. In some cases, both joints may bend downward, causing the toes to curl under the foot. In the variation of mallet toe, only the distal joint bends downward.
Other symptoms may include:
- Pain and stiffness during movement of the toe
- Painful corns on the tops of the toe or toes from rubbing against the top of the shoe's toe box
- Painful calluses on the bottoms of the toe or toes
- Pain on the bottom of the ball of the foot
- Redness and swelling at the joints
If you have any of these symptoms, especially the hammer shape, pain or stiffness in a toe or toes, you should consider consulting your physician. Even if you're not significantly bothered by some of these symptoms, the severity of a hammertoe can become worse over time and should be treated as soon as possible. Up to a point hammertoes can be treated without surgery and should be taken care of before they pass that point. After that, surgery may be the only solution.
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What are the types of hammertoe?
Essentially, there's one consistent type of hammertoe — the condition in which your toes are contracted into a hammer or upside-down "V" shape.
However, depending on its severity, hammertoe is characterized into two forms:
- Flexible hammertoe is hammertoe in which the joints of the toes are still moveable or flexible and can be treated with nonsurgical therapies.
- Rigid hammertoe is the more serious condition in which the joints' muscles and tendons have lost any flexibility and the contraction cannot be corrected by nonsurgical means. As a result, surgery is generally required to deal with the problem. This is why it's important to consult a physician as soon as the problem is recognized for the possibility of successful nonsurgical treatment.
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What does the doctor do to diagnose a hammertoe?
Your doctor is very likely to be able to diagnose your hammertoe simply by examining your foot. Even before that, he or she will probably ask about your family and personal medical history and evaluate your gait as you walk and the types of shoes you wear.
You'll be asked about your symptoms, when they started and when they occur. You may also be asked to flex your toe so that your doctor can get an idea of your range of motion. He or she may order x-rays in order to better define your deformity.
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What are the nonsurgical treatments for hammertoes?
If your hammertoe problem is diagnosed as flexible hammertoe, there are a number of nonsurgical treatments that may be able to straighten out your toe or toes and return them to their proper alignment.
- Padding and Taping. Your physician may pad the boney top-part of your hammertoe as a means of relieving pain, and may tape your toes as a way to change their position, correct the muscle imbalance and relieve the pressure that led to the hammertoe's development.
- Medication. Anti-inflammatory drugs such as aspirin and ibuprofen can help deal with inflammation, swelling and pain caused by your hammertoe. Cortisone injections may be prescribed for the same purpose. If your hammertoe is a consequence of arthritis, your physician may prescribe medications for that.
- Orthotics. Orthotics are shoe inserts that can help correct mechanical foot-motion problems to correct pressure on your toe or toes and reduce pain.
- Changing shoes. You should seek out shoes that conform to the shape of your feet as much as possible and provide plenty of room in the toe box, ensuring that your toes are not pinched or squeezed. You should make sure that, while standing, there is a half inch of space for your longest toe at the end of each shoe. Make sure the ball of your foot fits comfortably in the widest part of the shoe. Feet normally swell during the course of the day, so shop for shoes at the end of the day, when your feet are at their largest. Don't be vain about your shoe size — sizes vary by brand, so concentrate on making certain your shoes are comfortable. Remember that your two feet are very likely to be different sizes and fit your shoe size to the larger foot.
- Low-heel shoes. High heels shift all your body weight onto your toes, tremendously increasing the pressure on them and the joints associated with them. Instead, wear shoes with low (less than two inches) or flat heels that fit your foot comfortably.
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What are the surgical treatments for hammertoe?
Surgery is the approach that is often necessary to correct hammertoe that fails to respond to nonsurgical management. Surgery is appropriate when the muscles and tendons involved in a hammertoe problem have become so tight that the joints are rigid, misaligned and unmovable.
There are a number of surgical techniques for dealing with the complex range of joint, bone, muscle, tendon and ligament abnormalities that define each hammertoe's make-up. To correct a hammertoe deformity, the surgeon's goal is to restore the normal alignment of the toe joint, relieving the pressure that led to the hammertoe's development (this should also relieve the pain, as well).
To do this, he or she may:
- Remove part of the boney structure that creates a prominence at the top of the joint
- Tighten or loosen the muscles, tendons and ligaments around the toe joints
- Realign the toe bones by cutting one or more and shifting their position, realigning muscles, tendons and ligaments accordingly
- Use screws, wires or plates to hold the joint surfaces together until they heal
- Reconstruct a badly damaged joint or replace it with an artificial implant
Keep in mind that the intention of hammertoe surgery is to relieve pain and restore function and normal alignment. Surgery often improves the appearance of the affected feet, but that's neither a goal nor a guaranteed result.
Hammertoe surgery is most often done on an outpatient or day-surgery basis, usually with a local anesthetic technique called an ankle block. The surgery typically takes an hour or two to perform.
Following your surgery, you will stay in the Recovery Room for several hours while the anesthetic wears off. For your safety, you will be required to have someone to drive you home. You should keep in mind that any surgery carries with it very small-but-possible risks of complications such as allergic reaction to anesthesia, bleeding and infection.
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What happens after the surgery?
Before you leave the hospital, your toes will be wrapped in bandages to hold them in place and you will receive instructions on maintaining those dressings and on wearing a special post-surgical shoe to protect your foot. You may need to use a cane or crutches for the first several days and to be careful about putting weight on your foot. You should try to keep your foot elevated and treated with ice as directed for several days. While your stitches may be removed in a couple of weeks, you will continue to need to utilize the bandages and shoe for as long as eight weeks.
You should plan on wearing athletic shoes or soft leather shoes — and no high heels — for several months once your bandages have been removed.
Your doctor may prescribe exercises to improve the range-of-motion of your toes, such as stretching them and picking up objects such as marbles and handkerchiefs with them.
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What are the chances of the hammertoe's recurrence?
The goal of your surgery is to remove pain and realign the bones, muscles, ligaments and tendons in your toes to restore your ability to engage in normal activities.
Your goal following surgery and recovery is to keep the hammertoe from developing all over again, which is quite likely if you return to wearing high-heel shoes and shoes that are too tight.
Issues such as a family propensity for developing hammertoes or having arthritis or a neuromuscular disease are things over which we have no control. However, the major factors in hammertoe development are matters that we can control, and preventing recurrence of hammertoes likely means changing your behavior.
Wear roomier shoes
- Seek out shoes that conform to the shape of your feet as much as possible and provide plenty of room in the toe box, ensuring that your toes are not pinched or squeezed.
- Make sure that, while standing, there is a half inch of space for your longest toe at the end of each shoe.
- Make sure the ball of your foot fits comfortably in the widest part of the shoe.
- Since feet normally swell during the course of the day, shop for shoes at the end of the day, when your feet are at their largest.
- Don't be vain about your shoe size — sizes vary by brand, so concentrate on making certain your shoes are comfortable.
- Remember that your two feet are very likely to be different sizes and fit your shoe size to the larger foot.
Don't wear high-heel shoes
- Avoid high heels, which shift all your body weight onto your toes, increasing the pressure on your toes and their joints tremendously.
- Wear shoes with low (less than two inches) or flat heels that fit your foot comfortably.
Wear orthotics to correct mechanical movement problems
- Orthotics are shoe inserts that can help correct mechanical foot-motion problems to reduce pain and prevent worsening of your hammertoe.
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For Additional Information
You can find additional information about hammertoe at web sites sponsored by government agencies, societies and healthcare institutions. It should perhaps be noted that the World Wide Web is open to many sources posting questionable information and promises, and you are encouraged to seek information from established, reputable organizations.
Likely sources include:
The American College of Foot and Ankle Surgeons
(www.acfas.org)
The American Podiatric Medical Association
(www.apma.org)
The American Orthopaedic Foot and Ankle Society
(www.aofas.org)
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