Hammertoe

What is a hammer toe? Anatomy and terms

In hammertoe, the proximal interphalangeal joint (PIP - the middle toe joint) protrudes upwards, while the tip of the toes points downwards. The curvature creates friction points on the upper leather of the shoe and pressure points under the metatarsal heads.

• Typical: hyperextension in the middle joint (PIP), flexion position in the end joint (DIP) variable
• The 2nd to 4th grades are often affected. Toe; the 2nd toe most common
• Sources of pain: pressure over the PIP (corn/clavus), calluses under the metatarsal heads (metatarsalgia), irritation of the bursa

Differentiation from similar findings:

• Claw toe: hyperextension in the metacarpophalangeal joint (MTP) and flexion in both interphalangeal joints; usually more pronounced forefoot overload.
• Mallet toe: Flexion position exclusively in the end joint (DIP), the middle joint is not hyperextended.
• Hallux valgus: misalignment of the big toe, can promote a hammer toe of the 2nd toe.

Causes and risk factors

Hammertoe is usually caused by an imbalance in the toe muscles and ligament structures. Repeated pressure, unsuitable footwear and static incorrect loads on the forefoot promote development.

• Tight, pointed or high shoes (pressure on the tip of the toe and the PIP joint)
• Hallux valgus with displacement of the 2nd toe
• Longitudinal and transverse arch disorders (arch arches/splay feet), forefoot overload
• Scars, injuries or dislocations in the toe area
• Rheumatoid arthritis and other inflammatory systemic diseases
• Neuromuscular diseases, diabetes with neuropathy (changed perception/strain)
• Genetic predisposition, weak connective tissue

It is important to differentiate between flexible (passively correctable) and rigid (fixed) deformities, as the treatment steps depend on this.

Typical complaints

• Pressure and friction pain over the bulging middle joint (PIP)
• Calluses/corns on the back of the joint or on the tip of the toes
• Burning pain under the metatarsal heads (metatarsalgia), especially when walking/standing
• Conflicts in the shoe, especially with narrow toe boxes or heels
• In advanced cases: inflamed bursa, local redness/swelling
• Occasionally numbness due to nerve irritation between the toes

The pain often increases as the day progresses. If you have skin lesions, weeping corns or signs of inflammation, you should seek immediate medical attention - especially if you have diabetes or circulatory problems.

Examination and diagnostics

The diagnosis is clinical: visualizing the position of the toes when standing and rolling, checking mobility (flexible vs. rigid) and pain points. It is important to assess the entire forefoot including the hallux position and transverse arch.

• Clinical examination with functional and stability tests
• Assessment of calluses, skin irritations and shoe marks
• X-ray while standing to assess the axis, joint position, tilting of the metatarsal bones
• Differential diagnoses: claw toe, mallet toe, Morton's neuroma, stress fracture, capsulitis, rheumatoid arthritis

Imaging is primarily used to plan operations or rule out other causes. Ultrasound or MRI are rarely necessary, for example in the case of unclear soft tissue changes.

Conservative therapy: treat gently at first

The aim of conservative treatment is to relieve pain, reduce pressure points and improve toe function. Complete retraction of the toe is primarily achieved in flexible deformities; In the case of fixed misalignments, the focus is on alleviating symptoms.

• Adjust shoes: sufficiently wide toe box, soft upper material, low heel height (max. 2-3 cm)
• Pressure protection/padding: silicone rings, toe caps, PIP padding against friction, toe separators in case of conflicts
• Insoles: Support of the transverse arch, pads to relieve the pressure on painful metatarsal heads
• Physiotherapy: mobilization of the toe joints, strengthening of the short foot muscles, gait training
• Targeted taping/orthotics: temporary correction for flexible hammer toe
• Podiatric measures: professional removal of corns, skin care
• Medication: if necessary, short-term anti-inflammatory painkillers (after consultation with a doctor)

Treating accompanying factors (e.g. hallux valgus or pronounced splayfoot) can also reduce hammertoe symptoms.

Simple exercises to do at home

Regular practice can improve mobility and activate the short foot muscles. Perform the exercises painlessly and increase slowly.

If pain persists during the exercises, please stop and seek medical advice.

Surgery: when does it make sense and what options are there?

Surgery is considered when conservative measures have been exhausted, there is a rigid misalignment and there is pain that is relevant to everyday life. The goal is a less painful, functional position - there is no guarantee that you will be free from symptoms.

• Soft tissue procedure for flexible hammer toe: e.g. B. Tendon extensions/relocations (flexor-to-extensor transfer) for muscular balance
• Bone/joint procedures for rigid deformity: PIP arthrodesis (fusion in functional extension) or resection arthroplasty
• Accompanying corrections: e.g. B. Weil osteotomy on the metatarsal bone for metatarsalgia, if necessary correction of a hallux valgus
• Fixation: temporary wires (K-wire) or implants, depending on the findings and technique
• Minimally invasive/percutaneous techniques are possible in selected cases

The type of anesthesia and method of administration (outpatient/inpatient) depend on the extent of the correction and comorbidities. Risks include: Wound healing disorders, infections, nerve irritation, persistent swelling, stiffness, over- or under-correction and recurrence.

Follow-up treatment and course

• Loading: often full weight bearing in a forefoot relief shoe; normal rolling is built up gradually
• Elevation and cooling to reduce swelling in the first few weeks
• Wound checks, thread removal after approx. 10-14 days (depending on the procedure)
• For wire fixation: removal after about 4-6 weeks, then mobility recovery
• Physiotherapy: mobilization of the neighboring joints, gait training, strengthening
• Swelling can last 3-6 months; Depending on the course, carefully increase the physical exertion after 8-12 weeks

The individual healing process varies and depends on the findings, accompanying corrections and consistent follow-up treatment.

Prevention: what you can do yourself

• Shoes with enough toe room and soft upper leather
• Regular foot and toe exercises to activate the short foot muscles
• Insoles/pads for splayed feet to relieve the forefoot
• Early treatment of hallux valgus to avoid displacement effects
• Skin care and podiatric control if you have a tendency to corns, especially if you have diabetes

Consistent prevention can reduce symptoms and slow progression, but does not replace medical evaluation if pain persists.

When should I see a doctor?

• Persistent pain or pressure points despite changing shoes and padding
• Signs of inflammation: redness, overheating, oozing, foul smell
• Open spots/ulcers, especially in the case of diabetes or circulatory problems
• Numbness, tingling or increasing misalignment
• After injury/trauma to the toes with misalignment or severe swelling

The earlier the causal factors are identified, the better conservative measures can be used.

Hammertoe, claw toe or mallet toe?

The exact name helps to choose a targeted therapy:

• Hammertoe: PIP upwards, toe tip often downwards – pressure on the back of the joint.
• Claw toe: Hyperextension in the metacarpophalangeal joint and flexion in both toe joints - often greater metatarsalgia.
• Mallet toe: Flexion position only in the end joint – pressure on the tip of the toe/skin irritation.

It is not uncommon for mixed forms to exist. The treatment is adapted to your individual foot statics and complaints.

Your orthopedic contact point in Hamburg

As a practice for conservative orthopedics in Hamburg-Winterhude, we provide you with differentiated advice on hammertoes - with a focus on non-surgical measures. If an operation makes sense, we will transparently explain the options, alternatives and realistic expectations to you. You can find us at Dorotheenstraße 48, 22301 Hamburg. You can easily get appointments online or by email.