Hammer toe - causes, symptoms and treatment options

The little toes are particularly important for mobility. They support the walking movement and allow fine motor movements that are essential for stabilisation, especially when walking. Therefore, the little toes should be able to perform their function without restriction. Malpositions of the little toes, such as the so-called hammer toe (Digitus malleus), are among the most common malpositions. It can permanently impair the function of the foot and must therefore be corrected at an early stage. Hammertoes are deformities that can affect all small toes. They consist of opposite bending of the metatarsophalangeal joint as well as the proximal and distal toe joint. They are usually the result of other static problems of the foot.

If a hammertoe deformity causes permanent discomfort, it is necessary to correct it with a surgical or non-surgical (conservative) therapy. In this article you will learn everything you need to know about hammertoe.

There are various malpositions of the little toes. In addition to the hammer toe, so-called claw toes also frequently occur.

Important to know: All small toes have three joints: the base joint, the joint near the body and the joint far from the body. In both malpositions, hammer toe and claw toe, the base joint and the joint near the body come into an opposing, bent position. This position of the end joint then determines whether it is a hammer toe or claw toe.

The difference between hammer toe and claw toe

How does a hammer toe differ from a claw toe? In a hammer toe, the end joint is bent in the opposite direction to the joint near the body. In this case, the proximal phalanx and the middle phalanx in the joint near the body stand up like a "small hammer". This often causes pain due to friction on the upper leather of the shoe. In claw toe, the tip of the toe is bent towards the ground and can also cause pain at the tip of the toe.

The mechanism that leads to a hammer toe can be of a very different nature. Anything that changes the balance of forces at the level of the metatarsophalangeal joint can cause a toe malposition such as a hammertoe.

The most common cause of a hammer toe is that there is instability at the tarsus of the big toe. This instability also can be a cause for a hallux valgus (crooked big toe, colloquially also bunion). So there is often a coincidence for Hammer toes and Hallux valgus.

This instability increases the pressure on the metatarsophalangeal joints of the small neighbouring toes to such an extent that the joint capsule is destroyed. As a result, the metatarsal head shifts downwards and the small toes lose their guidance. The result is the visible "accordion-like" contraction of the toes in all toe joints.

Other hammer toe causes

A short Achilles tendon or an injury in the lower leg (compartment syndrome) can also be a possible cause. The severity of a foot deformity such as hammer toe is best determined by the position of the proximal phalanx. In the progressive process of the disease, first the second (initial stage), then the third and later also the fourth and fifth little toe is affected. However, a hammer toe on the little toe occurs very rarely and should not be confused with the tailor's bunion. The tailor's bunion is the counterpart to the bunion of the big toe (hallux valgus) and is located on the fifth toe (little toe).

Even before the actual hammer toe forms, the first symptoms are discomfort under the forefoot. Once the foot deformity has developed, the hammertoe pain can be manifold. The first symptom is usually a "shoe fit problem", as the toe, which is curved upwards, rubs against the upper leather of the shoe. This often leads to further pressure pain or corns (clavus), and in some cases to inflammation. Furthermore, a hammer toe can shift so that it crosses over the big toe (digitus superductus).

Info: The most common symptoms of a claw toe are pain at the tip of the toe or inflammation of the toenail. If a hammer toe or claw toe has developed, this foot malposition is clearly recognisable to the foot surgeon due to the characteristic deformation of the toes.

Tonio Gottlieb, MD:

"A hammer toe can be very painful. Sooner or later, pressure points with calluses or corns form on the exposed toe joints. To prevent further progression of the condition, it is therefore advisable to make a reliable diagnosis and find a clear cause for the development of hammertoe."

 

To diagnose a hammer toe, the foot surgeon first starts with an anamnesis (patient interview), followed by a detailed physical examination. Most of the time, the specialist recognises this foot deformity already from the characteristic deformation. The small toes show the typical hammer toe "picture". The diagnosis is then confirmed by an X-ray under stress. This imaging procedure can also be used to reliably assess the stage of the foot malposition. Afterwards, the foot expert gives concrete recommendations for a successful hammertoe correction.

Depending on the severity of the deformity, the intensity of the pain or the individual patient's needs, Tonio Gottlieb, MD will talk to you to find the most suitable treatment option for correcting a hammer toe.

Can hammertoes be treated conservatively?

• A hammer toe deformity cannot be corrected by conservative (non-surgical) treatment methods, but only stopped.
• Common conservative treatments are:
  • Choice of appropriate footwear
  • Care of pressure sores or corns
  • Toe exercises
  • Padding
  • Reining in (with the help of a bandage)

Hammertoe surgery is always recommended,

•  if there are complaints and pain that limit the patient's mobility.
• if the risk of infection resulting from a long-lasting hammertoe deformity can be prevented by surgery.
• if, in connection with the hammertoe operation, the aim is to eliminate the cause (which is the case in most cases), i.e. that existing instabilities (e.g. due to a hallux valgus) are also surgically eliminated.

Surgical methods for diagnosis of hammer toe

The surgical techniques used in hammertoe surgery consist of correcting the balance of forces and the position of the toes.
This is done by:

• Stiffening of the toe joint close to the body (already restricted in mobility) in corrected position
• Extensor tendon lengthening
• Flexor tendon displacement

Occasionally, temporary wire fixation is necessary. Hammertoe surgery alone can be performed on an outpatient basis.

Tonio Gottlieb, MD:

"An untreated hammer toe can cause many problems in the long run, which can be avoided with a low-risk, outpatient operation. After hammertoe surgery alone, the foot is immediately able to bear weight again and the follow-up treatment is usually uncomplicated. Conservative therapy methods alone are not sufficient to correct a hammer toe deformity."

 

Info: Dear patients, we are not allowed to use hammertoe surgery before and after photos. We show you here photos what a foot with hammer toe and claw toe deformities can look like. 

A hammer toe operation is one of the uncomplicated procedures in foot surgery and can be performed on an outpatient basis. After the sole operation of a hammer toe, the foot can be fully loaded again directly after the operation. During the first two weeks, the patient should pay attention to careful wound care. In addition, it is necessary to wear a bandage shoe for about four weeks.

How long is one unable to work after hammertoe surgery?

The duration of the inability to work always depends on the type of occupational activity. Sitting office activities, for example, can be resumed immediately after the operation. The patient can usually start sporting activities again after about six weeks.

Can you prevent a hammer toe? What tips can the foot surgeon  give?

To prevent hammer toe, it is generally important to strengthen the foot muscles in order to increase the load-bearing capacity of the foot. Here we offer you seven foot exercises with which you can strengthen your feet. Special toe exercises can help to stabilise the foot as a whole. A visit to a physiotherapist is therefore helpful when symptoms begin. Here, the patient can learn effective exercises to correct a potential toe malposition. It is also important to wear the right shoes. The shoes should leave enough room for the toes to roll naturally when walking.

A hammer toe is disturbing for many patients at first and can be very painful as the condition progresses. The deformity can have a variety of causes, which need to be clarified by an expert in foot surgery. A hammer toe problem is very often caused by a curvature of the big toe (hallux valgus). The foot deformity can also occur in connection with a congenital flattening of the arch of the foot, as is the case with flat feet.

Patients who wear shoes that are too tight and too high for a long time can also suffer from the development of a hammer toe. In order to successfully treat a hammer toe, it is therefore important that the diagnosis is always comprehensive and cause-oriented. Based on his many years of experience as a foot surgeon and specialist for the whole foot, Tonio Gottlieb, MD can make an exact diagnosis, on the basis of which he will work out an individual treatment plan with you.

Tonio Gottlieb, MD:

"In some cases, patients come to me who have already had a hammertoe operation that did not solve the problem. If a hammertoe operation is unsuccessful, this can often be attributed to the fact that the therapy was not cause-oriented. That's why I always make sure to treat a hammertoe deformity in connection with the entire body statics. In my experience, this achieves the best results for the patient."