Hammertoes are the result of deformed toe joints, tight tendons that attach to the toe, and misaligned toe bones. The usual appearance of a hammertoe is a toe bent upward at the middle toe joint, so that the top of this joint rubs against the top of the shoe. The remainder of the toe is bent downward so that, instead of the entire toe bearing weight, only the tip of the toe bears weight. Pain can occur on the top of the toe, the tip of the toe, or in both areas.
Mallet toes and claw toes are similar to hammer toes, except that different joints on the toe are affected. The joint at the end of the toe buckles in a mallet toe, while a claw toe involves abnormal positions of all three joints in the toe. Hammertoes, mallet toes, and claw toes have similar symptoms and causes; therefore, treatments and preventive measures used to relieve hammertoe pain, frequently provide relief to painful mallet and claw toes as well.
Hammertoes are classified based on the mobility of the toe joints. There are two types:
- Flexible hammertoes: the joint has the ability to move. This type of hammertoe can be straightened manually.
- Rigid hammertoes: the joint does not have that same ability to move. Movement is very limited and can be extremely painful.
Hammertoes usually start out as mild deformities and get progressively worse over time. In the earlier stages, hammertoes are flexible and the symptoms can often be managed with changes in shoe styles and foot care products. But if left untreated, hammertoes can become more rigid and painful. Corns are more likely to develop as time goes on–and corns never really go away, even after trimming. In more severe cases of hammertoe, corn lesions may evolve into severe ulcerations. These lesions frequently occur in patients who have vascular disease or are Diabetic with neuropathy. The ulcerations can extend to the bone and result in infection and possible loss of digit or amputation.
Pain is caused by constant friction over the top of the contracted joint of the toe. This is the apex of the deformity. The skin in this area will become irritated and inflamed and painful over time. Corn formation (dry, hard, dead skin) can ensue causing even more pain over time. It may also be difficult to fit into some shoes due to the extra space the toe requires due to this deformity.
The most common symptoms of hammertoes include:
- The toe is bent upward at the middle toe joint, so that the top of this joint rubs against the top of the shoe. The remainder of the toe is bent downward.
- Pain upon pressure at the top of the bent toe from footwear.
- The formation of corns on the top of the joint.
- Redness and swelling at the joint contracture.
- Restricted or painful motion of the toe joint.
- Pain in the ball of the foot at the base of the affected toe. This occurs because the contracted digit puts pressure on the metatarsal head creating callouse and pressure on the ball of the foot.
Hammertoes are more commonly seen in women than men, due to the shoe styles women frequently wear: shoes with tight toe boxes and high heels. Genetics plays a role in some cases of hammertoes, as does trauma, infection, arthritis, and certain neurological and muscle disorders. But most cases of contracted toes are associated with various biomechanical abnormalities of the feet, such as flat feet and feet with abnormally high arches. These biomechanical abnormalities cause the muscles and tendons to be used excessively or improperly, which deforms the toes over time.
Hammertoes are a contracture of the toes as a result of a muscle imbalance between the tendons on the top of the toes (extensor tendons) and the tendons on the bottom of the toes (flexor tendons). If there is an imbalance in the foot muscles that stabilize the toe, the smaller muscles can be overpowered by the larger flexor and extensor muscles.
If a foot is flat (pes planus, pronated), the flexor muscles on the bottom of the foot can overpower the others because a flatfoot is longer than a foot with a normal arch. When the foot flattens and lengthens, greater than normal tension is exerted on the flexor muscles in the toes. The toes are not strong enough to resist this tension and they may be overpowered, resulting in a contracture of the toe, or a bending down of the toe at the first toe joint (the proximal interphalangeal joint) which results in a hammertoe.
If a foot has a high arch (pes cavus, supinated), the extensor muscles on the top of the foot can overpower the muscles on the bottom of the foot because the high arch weakens the flexor muscles. This allows the extensor muscles to exert greater than normal tension on the toes. The toes are not strong enough to resist this tension and they may be overpowered, resulting in a contracture of the toe, or a bending down of the toe at the first toe joint (the proximal interphalangeal joint) which results in a hammertoe.
Treatment, Self-Help, and Prevention
Pain can occur on the top of the toe, the tip of the toe, or in both areas. The following remedies are prescribed by doctors to relieve shoe pressure and pain in these toes; or, to help the toe lie straight, thus alleviating pain and preventing the hammertoe from becoming worse:
- Budin Hammertoe Splint extends the hammertoe and allows it to lie straight; thus, pain is alleviated in the top and tip of the toe.
- Adhesive foam corn pads. Use to protect painful and irritated areas on toes. Made with medical grade foam.
- Removable, comfortable, long lasting Gel Crest Pads straighten the toes and prevent them from rubbing against the tops of your shoes, relieving your pain.
- Foam toe sleeves will shield your toes from pressure and friction.
- Removable, long lasting Gel Toe Pads.
- Kerasal One Step Exfoliating Moisturizer Therapy gently exfoliates and softens hard, dry, dead skin.
- Exercise by stretching the toe straight for 10 seconds, and repeat for 3 to 5 minutes daily.
- Make sure your shoes are the correct length and width. Most pressure can be helped with proper fitting shoes.
- Wear flat shoes with a deep toe box. (Do not wear shoes with a heel higher than 1 inch.)
- Gentle massage with a cool linament will help to relieve your pain.
- If you ever experience open wounds, intense redness, or extreme pain see a podiatrist immediately.
If Conservative Care Fails
If conservative treatments fail and your symptoms persist, the doctor may recommend a surgical option to straighten the toe. The procedures used vary greatly, depending upon the reasons for the hammertoe. There are a number of different operations to correct hammertoes, the most common ones involve:
- Soft tissue corrections such as tendon transfers, tendon lengthening, and joint capsule repairs.
- Digital arthroplasty involves removal of bone from the bent joint to allow the toe to straighten. The temporary use of pins or K-wires may be necessary to keep the toe straight during the healing period. Joint implants are sometimes used to allow for a better range of motion in the toe following surgery.
- Digital arthrodesis involves the removal of bone from the bent joint and fusing the toe in a straight position. If the corn is due to a bone spur, the most common procedure used is an exostectomy, in which surgically removing it or filing it down removes the bone spur.
Because of the possible complications involved with any surgery, one should be sure to understand the risks that may be involved with surgery to correct hammertoes and remove bone spurs.