Hammer Toe
Julie Adkins and Jill C. Cash
Definition
A.A hammer toe is a deformity of the second, third, or fourth toe. The toe is bent at the middle joint, resembling a hammer.
Pathogenesis
A.Hammer toe results from shoes that do not fit properly or a muscle imbalance. Muscles work to straighten and bend the toes. If the toe is bent for long periods, the muscles tighten and cannot stretch out.
Predisposing Factors
A.Shoes that narrow at the toe push the toes into a bent position, making the toes rub against the shoe. Eventually, the toe muscles are unable to straighten the toe with any shoe or barefoot.
Common Complaints
A.My toe is bent.
B.I can’t find shoes to fit due to my bent toe.
C.I have a sore or callus on my toe because it won’t straighten out.
Other Signs and Symptoms
A.Formation of corns and calluses on the middle joint of the toe or on the tip of the toe.
B.Pain in the toes and feet.
C.Difficulty finding shoes to fit feet.
Potential Complications
A.Ulcers of the middle joint of the toe may develop, possibly leading to infection or osteomyelitis.
B.Patient may have chronic pain of the toe. Abscesses of corns and calluses may develop.
Subjective Data
A.Pain over the ball of the foot.
B.Toe rubbing on shoes.
C.Skin over top of toe is starting to thicken.
D.Toe/toes are crooked.
Physical Examination
A.Inspect:
1.Examine the extensor tendons of the toes for flexibility. It should be tight when the ankle is placed in plantar-flexion position.
2.Examine the metatarsophalangeal (MTP) joints for irritation and thickening.
3.Note corns and calluses on top of the toe if present.
B.Palpate:
1.Palpate over MTP joints. Note tenderness over the MTP joint and a positive MTP joint squeeze.
2.Note range of motion (ROM) of all toes and ankle.
Diagnostic Tests
A.X-rays:
1.X-rays are not routinely recommended. They rarely provide any additional information not found on physical examination.
2.X-rays should be performed if severe swelling, unusual color, or unequal movement/ROM of toes is present.
Differential Diagnosis
A.Hammer toe.
B.Rheumatoid arthritis.
C.Osteoarthritis.
D.Reflex sympathetic dystrophy—consider if there is extensive swelling and discoloration.
Plan
A.General interventions:
1.Conservative treatment consists of new shoes with soft, roomy toe areas. Shoes should be one-half inch longer than the longest toe. Sandals may help as long as they do not pinch or rub the affected area of the toe. Toe exercises can stretch and strengthen the muscles, and toes can be gently stretched manually. Advise using corn pads or cushions to cover calluses or thickened skin. Consider paring the large corns and calluses with sharp dissection. Toe spacers may also be suggested to use for comfort.
B.Pharmaceutical therapy:
1.Local steroid injection at the most painful MTP head may be considered, with reemphasis on passive stretching exercises.
Follow-Up
A.Consider injection of the joint if the case is severe. Aftercare treatment involves resting the foot for 3 days, wearing loose-fitting shoes, using a toe spacer, and applying ice for approximately 15 minutes every 4 to 6 hours.
B.Restart passive stretching of the foot after 3 to 4 weeks.
C.If pain recurs or persists, repeat injection at 6 weeks.
Consultation/Referral
A.Physical therapy for active assessment and treatment. Increasing the flexibility of the MTP joints and toes will prevent hammer toe.
B.Consider referral to a surgeon/podiatrist for evaluation for arthroplasty with or without fusion with K wires.
Individual Considerations
A.Adults:
1.Evaluate the patient’s ability to perform passive stretching exercises due to other comorbidities.
2.Assess patients with diabetes for corns and calluses. Monitor for infection, poor circulation, and/or decreased sensation in the feet.
3.Fall precautions should be discussed with patients at risk for falls who have pain/numbness of the foot or who wear adaptive footwear.
B.Geriatrics:
1.Orthoses may be inserted inside the shoe or custom-made to fit the foot to accommodate the toe’s deformity. Instruct patient and family to continually assess the foot’s pressure points, and to alert medical provider of any skin changes or signs of skin tears/ulcers.
2.No surgery is recommended in the absence of pain for elderly population.
3.Research indicates that surgical correction of hammertoes demonstrated significant improvement in older and younger adults with no associated increase in complications for geriatrics.
4.Educate and encourage proper foot care for geriatrics. Avoid tight shoes and high heels; monitor feet for discoloration, calluses and fungal infections; keep feet and toes dry and clean; trim nails straight across; and regularly see a podiatrist to assess for toenail fungus, ingrown toenails, and preventive measures of feet complications.