Hammer Toe

What is Hammer Toe

Hammer toe is a change in the shape (a deformity) of your toe. The deformity causes the middle joint of your toe to stay bent. This causes pain, especially when you are wearing shoes.

Hammer toe is a painful flexion deformity of the proximal interphalangeal joint in which the middle and distal phalanges are flexed down onto the proximal phalange.

The second toe is affected most often, and the condition is usually bilateral. Like hallux valgus deformity, hammer toe is usually the result of wearing shoes that are too tight in the toe box, although trauma has also been implicated.

As with bunion, hammer toe deformity occurs more commonly in females than in males. An inflamed adventitious bursa may accompany hammer toe and contribute to the patient’s pain.

A callus overlying the plantar surface of these bony prominences is usually present as well. High-heeled shoes may exacerbate the problem.

Hammer toe starts gradually. At first, the toe can be straightened. Gradually over time, the deformity becomes stiff and permanent.

Early treatments to keep the toe straight may relieve pain. As the deformity becomes stiff and permanent, surgery may be needed to straighten the toe.

What are the causes?

Hammer toe is caused by abnormal bending of the toe joint that is closest to your foot. It happens gradually over time. This pulls on the muscles and connections (tendons) of the toe joint, making them weak and stiff. It is often related to wearing shoes that are too short or narrow and do not let your toes straighten.

What increases the risk?

You may be at greater risk for hammer toe if you:

  • Are female.
  • Are older.
  • Wear shoes that are too small.
  • Wear high heeled shoes that pinch your toes.
  • Are a ballet dancer.
  • Have a second toe that is longer than your big toe (first toe).
  • Injure your foot or toe.
  • Have arthritis.
  • Have a family history of hammer toe.
  • Have a nerve or muscle disorder.

What are the symptoms?

The main symptoms of this condition are pain and deformity of the toe. The pain is worse when wearing shoes, walking, or running. Other symptoms may include:

  • Corns or calluses over the bent part of the toe or between the toes.
  • Redness and a burning feeling on the toe.
  • An open sore that forms on the top of the toe.
  • Not being able to straighten the toe.

Most patients complain of pain localized to the proximal interphalangeal joint and an inability to get shoes to fit. Walking makes the pain worse, whereas rest and heat provide some relief.

The pain is constant and is characterized as aching; it may interfere with sleep. Some patients complain of a grating or popping sensation with use of the joint, and crepitus may be present on physical examination.

In addition to pain, patients with hammer toe develop a characteristic flexion deformity of the proximal interphalangeal joint.

How is this diagnosed?

This condition is diagnosed based on your symptoms and a physical exam. During the exam, your health care provider will try to straighten your toe to see how stiff the deformity is. You may also have tests, such as:

  • A blood test to check for rheumatoid arthritis.
  • An X-ray to show how severe the deformity is.

Plain radiographs are indicated in all patients who present with hammer toe. Magnetic resonance imaging and ultrasound imaging of the toe are indicated if joint instability, an occult mass, or a tumor is suspected.

Based on the patient’s clinical presentation, additional testing may be warranted, including a complete blood count, erythrocyte sedimentation rate, and antinuclear antibody testing.

How is this treated?

Treatment for this condition will depend on how stiff the deformity is. Surgery is often needed. However, sometimes a hammer toe can be straightened without surgery. Treatments that do not involve surgery include:

  • Taping the toe into a straightened position.
  • Using pads and cushions to protect the toe (orthotics).
  • Wearing shoes that provide enough room for the toes.
  • Doing toe-stretching exercises at home.
  • Taking an NSAID to reduce pain and swelling.

If these treatments do not help or the toe cannot be straightened, surgery is the next option. The most common surgeries used to straighten a hammer toe include:

  • Arthroplasty. In this procedure, part of the joint is removed, and that allows the toe to straighten.
  • Fusion. In this procedure, cartilage between the two bones of the joint is taken out and the bones are fused together into one longer bone.
  • Implantation. In this procedure, part of the bone is removed and replaced with an implant to let the toe move again.
  • Flexor tendon transfer. In this procedure, the tendons that curl the toes down (flexor tendons) are repositioned.

Initial treatment of the pain and functional disability associated with hammer toe includes a combination of nonsteroidal antiinflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. Avoidance of repetitive activities that aggravate the patient’s symptoms, avoidance of narrow-toed or high-heeled shoes, and short-term immobilization of the affected toes may provide relief. For patients who do not respond to these treatment modalities, injection with local anesthetic and steroid is a reasonable next step.

To inject hammer toe, the patient is placed in the supine position, and the skin overlying the affected toe is prepared with antiseptic solution. A sterile syringe containing 1.5 mL of 0.25% preservative-free bupivacaine and 40 mg methylprednisolone is attached to a  -inch, 25-gauge needle using strict aseptic technique. The hammer toe is identified, and the needle is carefully advanced against the second metatarsal head. The needle is then withdrawn slightly out of the periosteum, and the contents of the syringe are gently injected. The operator should feel little resistance to injection.

Physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes injection.

If resistance is encountered, the needle is probably in a ligament or tendon and should be advanced or withdrawn slightly until the injection can proceed without significant resistance. The needle is removed, and a sterile pressure dressing and ice pack are applied to the injection site.

Differential Diagnosis

The diagnosis of hammer toe is usually obvious on clinical grounds alone. Bursitis and tendinitis of the foot and ankle frequently coexist with hammer toe.

In addition, stress fractures of the metatarsals, phalanges, or sesamoid bones may confuse the clinical diagnosis and require specific treatment.

Complications

Failure to identify primary or metastatic tumor of the foot that is causing the patient’s pain can have disastrous results.

The major complication of injection is infection, although this should be exceedingly rare if strict aseptic technique is followed.

Approximately 25% of patients complain of a transient increase in pain after injection, and patients should be warned of this possibility.

Follow these instructions at home:

  • Take over-the-counter and prescription medicines only as told by your health care provider.
  • Do toe straightening and stretching exercises as told by your health care provider.
  • Keep all follow-up visits as told by your health care provider. This is important.

How is this prevented?

  • Wear shoes that give your toes enough room and do not cause pain.
  • Do not wear high-heeled shoes.

Contact a health care provider if:

  • Your pain gets worse.
  • Your toe becomes red or swollen.
  • You develop an open sore on your toe.
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