What is Hammer Toe?
Hammer toe is one of the most common deformities affecting the forefoot, resulting from an imbalance between the muscles that surround the joints of the lesser toes (meaning all toes except the big toe and the little toe, which are typically excluded from this specific classification).
The condition manifests as a toe that remains persistently bent downward at its middle joint. Since the lesser toes play an important, often underappreciated role in the sophisticated mechanism that allows the body to maintain balance, as well as in the proper distribution of body weight during standing and walking, this deformity can lead to a range of problems over time. These include compensatory changes in gait (the way a person walks), noticeable cosmetic alterations to the appearance of the foot, and, perhaps most importantly for patients, chronic pain along with an increased tendency to develop painful calluses at points of friction and pressure.
Numerous therapeutic approaches exist to manage hammer toe. While the initial approach generally favors conservative treatment options, such as wearing shoes with a wider toe box and using specialized shoe inserts (orthotics), surgical correction remains available and may become necessary in more advanced or persistent cases.
Causes
To understand why hammer toe develops, it helps to first understand the basic muscle anatomy of the foot. The muscles of the foot can be divided into two broad categories:
- Extrinsic muscles, which originate outside the foot itself, anchored to a bone in the lower leg, and which are responsible for the foot’s larger, more powerful movements;
- Intrinsic muscles, which are located entirely within the foot itself, and which are instead responsible for finer, more precise movements and for maintaining the proper alignment and stability of the toes.
The underlying structural defect that produces hammer toe arises from an imbalance between weaker intrinsic muscles and comparatively stronger extrinsic muscles. Under normal circumstances, the combined, coordinated action of these two muscle groups produces a specific, healthy resting position of the foot and toes. However, any disruption to this delicate physiological balance inevitably tips the scales in favor of the stronger extrinsic muscles, resulting in an abnormal flexion (bending) of the affected toe or toes.
To understand the anatomy more precisely, the forefoot is composed of five toes, each of which possesses three individual joints, with the exception of the first toe (the big toe, or hallux), which typically has only two joints. In the specific case of hammer toe, the affected toe becomes bent at its middle joint, known as the proximal interphalangeal (PIP) joint.
Footwear as a Common Trigger
Wearing inappropriate or ill-fitting footwear is one of the most common and preventable causes of this muscular imbalance. For example, shoes that narrow sharply toward the toe box push the smaller toes into a persistently flexed (bent) position over time. This pressure is further worsened by high-heeled shoes, which push the foot forward and downward against the front of the shoe, substantially increasing both the pressure placed on the toes and the degree of curvature forced upon them.
Other Contributing Causes
Beyond footwear, numerous other possible causes can contribute to the development of hammer toe, spanning both congenital conditions (present from birth) and acquired conditions that develop later in life:
- Neuromuscular disorders, which can disrupt the normal balance of muscle activity controlling the toes;
- Diabetes, particularly when accompanied by peripheral nerve damage (neuropathy) affecting the feet;
- Inflammatory arthropathies, joint diseases characterized by chronic inflammation;
- Intrinsic muscle imbalance, occurring independently of any other identifiable underlying condition;
- Bunions (hallux valgus), a deformity of the big toe that can crowd and displace the adjacent lesser toes;
- Abnormally long metatarsal bones, resulting from congenital anatomical variations;
- Flat feet, which alter the normal biomechanics and weight distribution across the foot;
- Specific underlying diseases, such as rheumatoid arthritis and Charcot-Marie-Tooth disease, an inherited neurological disorder that affects peripheral nerves and can significantly weaken the small muscles of the foot.
From a broader epidemiological perspective, hammer toe becomes progressively more common with advancing age and occurs more frequently in women, likely reflecting, at least in part, differences in typical footwear choices between the sexes over a lifetime. The medical literature also notes a notable degree of familial tendency, suggesting that genetic factors may predispose certain individuals to developing this condition.
Symptoms
Hammer toe is fundamentally a chronic, progressive deformity, meaning that, without intervention, it tends to systematically worsen over time rather than remaining stable or improving on its own.
The condition presents with a visible flexion (bending) of the affected joint, particularly the proximal interphalangeal joint (the middle joint of the toe), which is frequently accompanied by redness and pain that is characteristically worsened by walking and by the pressure and friction of wearing shoes.
In the early stages, the affected toe typically remains flexible, meaning it can still be manually straightened. However, in the absence of appropriate treatment, the toe can gradually become progressively stiffer, eventually becoming permanently locked in its contracted, bent position. This occurs because, when a toe remains in a flexed position for a prolonged period, the surrounding muscles and joint structures themselves undergo a process of contraction, gradually losing their normal ability to stretch and lengthen back to a straight position.
As the condition progresses, the severity of symptoms tends to gradually increase, consistent with its chronic, progressive nature. Over time, this can lead to noticeable alterations in the patient’s normal gait (walking pattern), driven both by the pain the patient experiences and by an instinctive, spontaneous tendency to shift weight toward a less painful area of the foot while walking.
Additional skin changes commonly develop on and around the affected toe as a direct result of the abnormal position and increased friction, including:
- blisters;
- calluses, thickened areas of skin that develop at points of repeated friction or pressure;
- ulcerations, particularly in patients with diabetes or reduced foot sensation;
- general skin irritation and inflammation of the affected area.
Diagnosis
The diagnosis of hammer toe is typically established through clinical examination, meaning it can usually be confidently identified simply through a thorough physical examination performed by a physician during an office visit. This clinical assessment is generally followed by imaging studies, which help further characterize the specific nature and severity of the deformity:
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X-ray (radiography), which allows the physician to visualize the bony alignment of the affected toe joints and to assess the degree of deformity present;
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Magnetic Resonance Imaging (MRI), reserved for selected cases in which more detailed information about the surrounding soft tissue structures, tendons, or ligaments is required.
Patients with diabetes or those experiencing reduced sensation in the feet may require additional specialized testing to evaluate any potential underlying neurological contribution to the joint deformity, specifically to assess for the presence of peripheral neuropathy, which can both cause and complicate hammer toe deformities and requires careful, specialized management to prevent serious complications such as foot ulcers.
Treatment
Hammer toe is, as previously discussed, a chronic and progressive deformity, meaning that it is generally not expected to resolve spontaneously on its own without some form of active intervention. However, the overall prognosis for patients who receive appropriate treatment remains generally favorable.
Although hammer toe deformities can become extremely painful and, as a result, can have a significant negative impact on a patient’s overall quality of life and daily functioning, conservative treatment approaches are typically attempted first, before surgical correction is seriously considered. These conservative measures include:
Conservative Treatment Options
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Shoe insoles or orthotic inserts, custom or over-the-counter devices designed to help redistribute pressure away from the affected toe and improve overall foot mechanics;
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Shoes with a wider toe box, specifically chosen to accommodate the deformity and to help relieve pain, which is particularly common when the affected toe rubs against the top or sides of a tightly fitting shoe. Patients are often advised to consider purchasing shoes a half-size larger than their usual size to provide additional room for the toes;
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Avoiding high-heeled shoes, due to the continuous increase in pressure that this type of footwear transfers directly onto the forefoot, worsening both symptoms and the underlying deformity over time;
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Specific stretching and strengthening exercises, which can help lengthen and strengthen the muscles of the foot. Useful exercises include gently stretching the toes manually on a daily basis, attempting to pick up small objects from the floor using only the toes (sometimes called “towel curls” or practicing a “prehensile” grasping action with the foot), or scrunching up a towel placed flat on the floor using only the toes;
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Periodic professional treatment of any calluses that may have developed as a result of the deformity, helping to reduce discomfort and prevent skin breakdown.
In many cases, these conservative measures are sufficient to achieve a satisfactory improvement in symptoms, allowing patients to manage the condition effectively without surgery. However, when conservative treatment proves insufficient, particularly in cases where the affected joint has already become permanently and irreversibly stiff (a “fixed” or rigid hammer toe), surgical intervention becomes the only remaining effective option.
Surgical Treatment Options
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Tendon lengthening: For patients whose toe joint remains flexible, the condition can often be successfully treated simply by surgically lengthening the specific tendons responsible for the underlying muscular imbalance causing the toe to bend.
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Tendon transfer: Some patients with a still-flexible toe joint may also benefit from a surgical procedure in which tendons are transferred from the underside of the toe to its upper surface, helping to actively pull the joint back into a straighter, more natural position.
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Arthrodesis (joint fusion): Patients whose hammer toe has already become permanently fixed and rigid may require tendon lengthening performed in combination with arthrodesis, a surgical procedure that involves removing a small portion of bone from within the affected toe joint in order to allow the toe to be fully extended and straightened once again. Following this bone removal, an external wire, an internal pin, and/or a small internal plate is typically inserted to hold the bones securely in the correct position until they have had adequate time to fuse together permanently.
These surgical procedures can generally be performed under local anesthesia on an outpatient (day surgery) basis, meaning most patients are able to return home on the same day as their procedure.
Recovery After Surgery
Depending on the specific surgical procedure performed, the particular technique used, and the individual preferences of the treating surgeon, the postoperative recovery period can vary considerably from patient to patient. The most common postoperative protocol typically involves a period of partial weight-bearing, using only the heel for support while wearing a special postoperative surgical shoe, for approximately 2 to 6 weeks, before gradually transitioning to a supportive, rigid athletic shoe. It is worth noting that patients who are smokers or who have diabetes may require a notably longer healing time, since both of these factors are well known to impair normal wound healing and bone fusion.
Potential Postoperative Complications
As with any surgical procedure, certain complications can arise following hammer toe surgery, with the specific risks depending somewhat on the particular surgical technique used. Among the most commonly reported complications are:
- infections at the surgical site;
- pseudoarthrosis, meaning a failure of the bone to properly fuse following an arthrodesis procedure;
- hematomas (localized collections of blood beneath the skin);
- numbness or altered sensation in the affected toe;
- recurrence of the original deformity.
Unfortunately, recurrence rates (meaning the reappearance of the hammer toe deformity despite having undergone surgical correction) remain relatively significant, reported at up to 10% in the medical literature. This means that as many as 1 in every 10 patients who undergo surgical correction may eventually develop a recurrence of hammer toe over time, a fact that is important for patients to discuss thoroughly with their surgeon when weighing the potential risks and benefits of surgical treatment.
Sources and Bibliography
- Goransson M, Constant D. Hammertoe. StatPearls Publishing, National Center for Biotechnology Information (NCBI).
- American Academy of Orthopaedic Surgeons (AAOS). Hammer Toe
- Mayo Clinic. Hammertoe and mallet toe: Symptoms and causes
- American College of Foot and Ankle Surgeons. Hammertoes
- NHS. Hammer toe
- Cleveland Clinic. Hammertoe
