A hammer toe is abnormally bent at one of the toe joints, resulting in a hammer-like appearance. There are numerous causes, including tight-fitting shoes or foot deformities. Symptoms include pain or discomfort during certain activities or when wearing particular shoes. Treatment can be surgical or non-surgical, including orthotics, better-fitting shoes, padding, and cushions.
A hammer toe occurs when a toe is abnormally bent at one of the joints, giving it a "hammer-like" appearance.
Hammer toes have many causes, including poorly fitted shoes, wearing particular shoes (high heels), trauma, tendon imbalance, long toes, diabetes, inflammatory conditions like rheumatoid arthritis, and flat feet (pes planus).
Symptoms consist of toe pain with particular shoes and specific activities.
Non-surgical treatments consist of orthotics (pre-made or custom-made), toe pads, cushions, and shoes that are wide at the toe area.
In some cases, surgery may be necessary.
Anatomy of the toes and feet
To understand hammer toes, we must first review the normal anatomy of the toes and feet.
As shown above, the bones of the foot include the following:
- Tarsal bones at the base
- Metatarsal bones
Types of hammer toes
There are three types of hammer toe: classic, claw toe, and mallet toe.
Classic hammer toe
As shown in the images, there are two joints for the second and the fifth toe. The proximal interphalangeal (PIP) joint is closer to the. The distal interphalangeal (DIP) joint is furthest from the foot.
The above-shown image depicts the classic hammer toe. In this type of deformity, there is excessive flexion (bending) at the PIP joint, but the DIP joint is normal.
Above you can see the claw toe, formed by abnormal flexion (bending) at both the PIP and DIP joints.
In a mallet toe, the PIP is normal, but the DIP is flexed.
For the purposes of this article, we will use the term "hammer toe" to describe any of the three types mentioned above.
Causes of a hammer toe
A hammer toe is caused by an imbalance of the toe's various tendons, bones, and ligaments.
Various conditions and choices can lead to a hammer toe:
- Poorly fitting shoes
- Wearing high heels
- Having long toes
- Imbalance of the muscles or tendons of the toes
- Inflammatory conditions like rheumatoid arthritis
- Having flat feet (pes planus)
- Hallux valgus (a large toe deformity)
Even though there have been no conclusive studies for a genetic basis of hammer toes, the foot deformities that lead to hammer toes appear to have a genetic basis.
Symptoms of a hammer toe
The symptoms of hammer toe include:
- Pain with certain activities like running, hiking, or prolonged walking.
- Discomfort when wearing certain shoes, like high heels.
How is hammer toe diagnosed?
Your doctor will take a history, which should elicit the symptoms mentioned above. A physical examination will demonstrate abnormal bending at the toe joints.
Imaging studies like plain x-rays will allow your physician to view any underlying bone abnormalities, such as fractures, spurs, arthritis, or osteoporosis (thinning of the bones). Second, x-rays can help your physician view the lengths of the metatarsal bones. Finally, hallux valgus, a condition where the large toe deviates to the side, can be diagnosed by plain x-rays. If surgery is being considered, an x-ray should be done beforehand.
Avascular necrosis occurs when the bone tissue dies from a lack of blood supply; if suspected, a magnetic resonance imaging (MRI) test should be ordered. In addition, an ultrasound, which uses sound waves, can evaluate the blood supply to that toe. Avascular necrosis occurs at the metatarsal heads (where it joins the phalanx), with the 2nd being the most common.
Hammer toe treatment options
Some hammer toes do not cause symptoms or require treatment. Others need treatment due to the pain and discomfort. The treatment of hammer toes can be non-surgical or surgical.
Non-surgical hammer toe treatment methods include:
- Shoe inserts or orthotic devices. These can be prefabricated or custom-made. To relieve hammer toe symptoms, a custom orthotic is usually needed; however, some prefabricated orthotics can also relieve symptoms.
- Wide toe box shoes. Some shoes are wide throughout, while others are just wide at the toe area, called the toe box. Some cases of hammer toe will respond to shoes that are wide at the toe box.
- Padding and cushions. Numerous over-the-counter types of toe padding, separators, and cushions could help your hammer toe. For example, some people only have hammer toe symptoms when hiking, running, prolonged walking, or engaging in certain sports. For these specific activities, different pads or cushions could eliminate the symptoms.
If symptoms do not resolve by non-surgical treatment, surgery will be considered. There are various types of surgical procedures, and most can be done in the doctor's office with a numbing of the toe, called a digital block.
Tendon surgery aims to balance the forces on the toe's top (dorsum) and bottom (plantar surface) by cutting certain tendons. In other cases, the bones could be causing the problems. In these cases, the surgeon operates on the bones, sometimes placing a steel pin or rod to keep the toe straight while healing. These pins and rods are usually removed one month later.
The important thing to note is that hammer toes do not go away on their own. They may stay the same with minor or no symptoms; however, some worsen over time. See your physician or foot specialist for evaluation and treatment if you have pain or discomfort or find the hammer toe annoying.