WHAT IS A HAMMER TOE?
A hammer toe is a complex deformity involving any of the lesser toes (2nd, 3rd, 4th, 5th) and sometimes can involve the big toe. It is a shift of the toe bones into improper positions leading to pain and loss of function. The players involved in a hammer toe are: the three bones of the toe (distal, middle and proximal phalanges). The lesser toe joint (metatarsophalangeal joint), the 2nd, 3rd, 4th, and 5th long bone (metatarsal), and the tendons that flex the toe upwards (dorsiflexion) and the tendons that flex the toe downward (plantar flexion). It is most commonly seen in the 2″d toe. Hammer toe of the big toe (Hallux Malleus) is much less common.
Hammer toes develop when there is an imbalance of the muscles and tendons that pull the toe up and down. The toe will then buckle. The bend in the joints of the toe can be mild to severe. In some cases, the hammer toe is noticed when the foot at rest and straight when standing. In other cases, the toe is rigidly buckled and does not straighten. Hallux malleus usually involves a neuralgic component.
The toe bone closest to the foot will flex upwards at its joint. The next toe bone will flex downwards at their joint. This combination of misaligned joints forms the buckling of the toe and the prominence of the knuckle of the toe. With progression of the deformity, the ligaments hold the toe in the joint with the long bone (metatarsal) will stretch and tear leading to the dislocation of the toe (plantar plate tear). The toe may deviate to the left or the right, in some cases. A hammer toe deformity is progressive and will worsen over time.
When just the tip of the toe flexes downward it is called a mallet toe. This is corrected in a similar fashion comparable to a true hammer toe.
WHAT ARE THE SYMPTOMS OF A HAMMER TOE?
Some patients may have a very severe hammer toe with no pain, while others with a mild hammer toe may have significant pain. Most patients will complain of a rubbing, pressure pain over the knuckle. Certain shoes will be difficult to fit and wear. There can be pain in the joint of the toe. There may be pain over the top of the foot as the tendons contract and pull the toes into their deformed position. A painful callus (extra growth of hard skin) can develop over the tip of the toe, the knuckle, and on the ball of the foot. If the ligament at the metatarsal begins to tear, patients will note pain in the ball of the foot just behind the toe. Some days may be more painful than others if the bursa (the gel-like sac of fluid between the bone and skin) becomes inflamed from friction causing a bursitis. Numbness to the toe can develop with constant friction of the skin and nerve over the hammer toe bump.
WHAT CAUSES A HAMMER TOE?
Hammer toes are primarily a genetic deformity. This means that most people that have a hammer toe may have inherited it from someone in their family. Some patients form only one hammer toe while others will form several or all the toes into a hammer toe. However, there are factors that can increase the speed and severity in which the deformity will develop. A high arched foot (pes cavus, supination) leads itself to an uneven pull of the tendons to the toe allowing of buckling of the toes. Significant use of high heel shoes with their small toe box can help to develop hammer toes. With a bunion (hallux abducto valgus) deformity the big toe progressively shifts towards the 2nd toe, forcing the 2nd toe to hammer to move out of the way. Damage to the ligament on the bottom of the joints can lead to a plantar plate tear and eventually a deformed toe.
Diagnosis is simply achieved by the clinical examination and x-rays of the patient. Dr. Heath will listen to your complaints, symptoms and goals. The examination involves a hands-on analysis of the patient’s foot and evaluating their gait. Radiographs (x-rays) of the feet will be obtained in the office and reviewed with the patient. The position of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated deformities.
CONSERVATIVE TREATMENT FOR A HAMMER TOE:
Conservative treatments rely on their ability to accommodate the hammer toe deformity. This can be achieved by wearing appropriate shoes with a wide toe box. If the shoe has room for the protruding bone, there can be less pain and discomfort. Padding over the knuckle can take the pressure off the area. Any painful callus can be removed in the office and will need to be maintained, as they will return. Toe braces and splints can keep the toe straight while in shoes taking pressure off the toe. Ice and anti-inflammatory can reduce the irritation when there is a flare. custom molded orthotics, can be made as an important tool to slow the progression of the hammer toe and prevent recurrence after surgery.
There is not a conservative way to stop a hammer toe from forming or progressing. There is no conservative way to reverse the deformity. Braces and straps cannot reverse the malposition of the joints and bones and can only help relieve pain while they are used.
SURGICAL TREATMENT FOR HAMMER TOE:
Dr. Heath will always recommend and attempt conservative treatment when appropriate. However, when a hammer toe deformity becomes painful and many shoes are difficult to wear, surgical repair may be indicated.
SOME FACTS TO CONSIDER ABOUT HAMMER TOE TREATMENT:
There are many different procedures and techniques to repair a hammer toe deformity. It is the responsibility of the surgeon to investigate each specific aspect of the hammer toe for each individual patient to formulate the proper procedure for repair. Dr. Heath will use the information gained from the patient’s symptoms, age, activity level, lifestyle goals, the severity of the deformity, the clinical examination, the patient’s gait, and the x rays to make a recommendation on the proper procedure.
Hammer toe surgery is performed in a step wise approach, evaluating the amount of correction achieved as each step is performed. The more the severe deformity the more steps are needed.
MILD TO MODERATE HAMMER TOE: 2ND 3RD 4TH TOES
A small special incision is made on the top of the toe at the knuckle, removing any extra skin or callus. A small portion of the prominent knuckle is removed. Given room for the toe to straighten. The 2nd bones
(middle and proximal phalanx) are held in place with a small plastic permanent implant. The implant holds the bones in their new corrected position while the bone healed. If the toe is slightly elevated or deviated at
the level between the toe and foot, a small incision will be made at the level of the joint to release the tight ligaments bringing level.
MODERATE TO SEVERE HAMMER TOE: 2ND 3RD 4TH TOES
When there is a more rigid deformity, the forces acting to deform the toes are stronger. This demands more steps to get the toe straight. The steps mentioned above are performed. A second small incision is made over the toe joint to the foot. The major ligaments around the toe and the long bone (metatarsal) are released step by step until the toe is straight. The tendon that brings the toe upwards may be lengthened. If the toe is still not fully corrected if the pressure at the level of the toe and the long bone is too great. A small portion of the long bone will be removed to decompress the joint and allow for the toe to straighten.
WHEN A TOE IS TURNED TO THE SIDE OVER LAPPING ANOTHER TOE:
A precision cut is made at the head of the metatarsal (osteotomy). This bone is now slid back, shortening it. Reducing the pressure in the joint. This bone is then stabilized with two small dissolvable plugs or a small
metal screw which holds the bone in its new corrected position while the bone heals.
5TH TOE HAMMER TOE: ARTHROPLASTY:
A hammer toe of the 5th toe usually presents with a large painful callus and a rotated toe. A small angled, double incision is made over the top of the toe at the knuckle. Removing any extra skin or callus. A precision bone cut is made to decompress the joint by removing a small portion of the toe bone (proximal phalanx) Dr. Heath will close the special incision when the skin is brought together, the toe will rotate into a corrected position.