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Hammer toe

Hammer toe is a common foot deformity in which one or more of the lesser toes—typically the second, third, or fourth—bends abnormally at the middle joint (proximal interphalangeal joint), causing the toe to curl downward in a flexed position resembling the head of a hammer.^[1]^[2]^[3] This condition arises from an imbalance between the intrinsic and extrinsic muscles, tendons, and ligaments around the toe joints, often leading to hyperextension at the metatarsophalangeal joint and hyperflexion at the proximal interphalangeal joint.^[4] The primary causes of hammer toe include prolonged pressure from ill-fitting footwear, such as shoes with narrow toe boxes or high heels, which force the toes into a bent position and tighten the surrounding tendons over time.^[1]^[3] Other contributing factors encompass structural foot abnormalities like high arches, flat feet, or long toes, as well as underlying medical conditions such as rheumatoid arthritis, diabetes, or neuromuscular disorders that disrupt muscle balance.^[2]^[4] Risk factors include female gender, older age, and a family history, with hammertoe accounting for up to 20% of foot and ankle problems and showing higher heritability, particularly when associated with conditions like hallux valgus or pes planus.^[4] Symptoms of hammer toe often manifest as pain or tenderness at the top of the bent joint, especially when wearing shoes, along with difficulty straightening the toe, swelling, redness, and the development of corns or calluses from friction.^[3]^[2] In advanced cases, the deformity can become rigid and fixed, leading to complications such as altered gait, metatarsophalangeal joint instability, or secondary issues like painful ambulation and shoewear intolerance.^[1]^[4] Diagnosis typically involves a physical examination to assess toe flexibility and joint alignment, often supplemented by weight-bearing X-rays to evaluate bone positioning and rule out associated conditions.^[3]^[2] Treatment begins conservatively with wider footwear, padding, orthotic inserts, toe exercises, and nonsteroidal anti-inflammatory drugs to relieve symptoms in flexible cases, while rigid deformities may require surgical interventions such as tendon release, joint fusion (arthrodesis), or osteotomy to restore alignment.^[1]^[4] Prevention emphasizes selecting well-fitting shoes with adequate toe space and addressing underlying foot issues early to maintain muscle balance.^[3]^[2]

Overview

Definition and Characteristics

Hammer toe is a progressive deformity of the lesser toes, most commonly affecting the second, third, or fourth toe, characterized by hyperextension at the metatarsophalangeal (MTP) joint and abnormal flexion at the proximal interphalangeal (PIP) joint, causing the toe to bend in a shape resembling the head of a hammer.^[4]^[2] This condition results from an imbalance between the intrinsic and extrinsic muscles of the foot, with weak intrinsic muscles allowing dominance of the extrinsic extensors, such as the extensor digitorum longus, leading to MTP hyperextension and secondary flexion at the PIP joint due to unopposed extrinsic flexors.^[4] Hammer toe is distinguished from similar toe deformities by the specific joint involvement: unlike mallet toe, which features isolated flexion at the distal interphalangeal (DIP) joint near the toenail, creating a bend only at the toe's tip, hammer toe primarily affects the middle joint while the DIP joint remains neutral or slightly hyperextended.^[4]^[3] In contrast, claw toe involves flexion at both the PIP and DIP joints, often accompanied by hyperextension at the metatarsophalangeal (MTP) joint, resulting in a more pronounced claw-like curl across multiple joints.^[4]^[3] The condition progresses through stages, beginning as flexible hammer toe, where the bent joint can still be passively straightened, and advancing to rigid hammer toe, in which the joint becomes fixed and immovable due to tightening of surrounding tendons and joint contracture.^[4]^[3] Hammer toe is one of the most common foot deformities, accounting for up to 20% of foot and ankle issues, with a higher prevalence in women, often linked to habits such as wearing tight or high-heeled footwear that exacerbates the muscle imbalance.^[3]^[1]

Anatomy of the Toe

The human toe consists of three small long bones known as phalanges in digits 2 through 5: the proximal phalanx, which articulates with the metatarsal bone; the middle phalanx; and the distal phalanx, which supports the toenail. The first toe, or hallux, has only two phalanges: proximal and distal. These bones are connected by three joints per toe (except the hallux, which has two): the metatarsophalangeal (MTP) joint at the base, which is a condyloid joint allowing flexion, extension, abduction, and adduction; the proximal interphalangeal (PIP) joint, a hinge joint permitting primarily flexion and extension; and the distal interphalangeal (DIP) joint, also a hinge joint for flexion and extension.^[5] Toe movement is facilitated by a network of tendons, ligaments, and muscles. The flexor digitorum longus tendon, originating from the posterior leg, inserts into the distal phalanges of toes 2-5 to enable plantar flexion, while the flexor digitorum brevis, an intrinsic foot muscle, provides finer control via its tendons to the middle phalanges. Conversely, the extensor digitorum longus from the anterior leg extends the toes by pulling on the dorsal aspects of the phalanges, supplemented by the intrinsic extensor digitorum brevis. Ligaments, such as the collateral ligaments stabilizing the MTP, PIP, and DIP joints, along with the plantar plate at the MTP joint, maintain joint integrity and prevent excessive deviation. Intrinsic muscles like the lumbricals and interossei further assist in flexion at the MTP joint and extension at the interphalangeal joints, ensuring coordinated action.^[5]^[6] The toes are integrated into the foot's broader anatomy, which includes five metatarsal bones forming the forefoot and connecting the phalanges to the midfoot. These metatarsals, along with the tarsal bones, contribute to the foot's arches—the longitudinal arch running along the inner foot and the transverse arch across the midfoot—which distribute weight and absorb shock during locomotion. Ligaments and the plantar fascia, a thick band of connective tissue from the heel to the toes, support these arches, promoting proper alignment of the toes by maintaining the foot's structural stability.^[7]^[6] In normal biomechanics, the balanced pull of flexor and extensor tendons keeps the toes aligned straight during the gait cycle. During the stance phase of walking, the flexor digitorum longus and brevis generate plantar flexion moments at the MTP joint to counter ground reaction forces, stabilizing the toes for propulsion, while extensors like the extensor digitorum longus ensure dorsal flexion to maintain contact and prevent buckling. This equilibrium, supported by intrinsic muscles, allows the interphalangeal joints to flex appropriately without deformity, optimizing force production up to approximately 14 Nm at the MTP joint during push-off.^[8]^[5]

Signs and Symptoms

Common Symptoms

Hammer toe is characterized by a prominent bend at the proximal interphalangeal (PIP) joint, leading to a hammer-like appearance of the toe. Individuals with this condition often experience pain and tenderness at the affected joint, which intensifies during walking or when wearing ill-fitting shoes due to pressure on the bent area.^[1]^[3] A common secondary symptom is the development of corns or calluses on the top of the toe or the ball of the foot, resulting from repeated friction against footwear. These skin thickenings can cause additional discomfort and may become painful if irritated.^[1]^[2]^[9] Patients frequently report difficulty in bending or straightening the toe, which progresses to stiffness over time and, in severe cases, renders the toe nearly immobile, making it challenging to wear standard shoes comfortably. This functional limitation can impair daily activities such as walking.^[1]^[3]^[2] Additionally, swelling, redness, or inflammation may occur around the joint, sometimes accompanied by a change in skin color, signaling irritation or early joint stress. These visible signs can worsen with prolonged pressure from shoes.^[1]^[2]^[9]

Associated Conditions

Hammer toe often develops in conjunction with hallux valgus (bunions), as the misalignment of the big toe pushes adjacent toes out of alignment, increasing pressure on the second toe and promoting flexion deformities.^[10] This altered biomechanics can also lead to metatarsalgia, where the hammer toe deformity causes hyperextension at the metatarsophalangeal joint, forcing the metatarsal head downward and concentrating weight on the forefoot ball, resulting in inflammation and pain.^[11]^[4] In patients with diabetes, hammer toe heightens the risk of ulcers and infections due to neuropathy-induced muscle imbalances that create prominent pressure points, leading to callus formation and skin breakdown on the dorsal or plantar surfaces of the toe.^[12] These ulcers are particularly prone to infection because of impaired wound healing and reduced sensation, potentially progressing to cellulitis, osteomyelitis, or even amputation if untreated.^[12]^[3] Advanced hammer toe can overlap with other deformities, such as crossover toe, where instability at the second metatarsophalangeal joint causes the toe to deviate medially and dorsally over the adjacent digit, often as a variant of the hammer toe contracture.^[4] In later stages, persistent flexion at the proximal interphalangeal joint may result in fixed joint contractures, tightening the surrounding tendons and ligaments, which further rigidifies the deformity and complicates correction.^[4] The deformity disrupts normal gait by causing uneven weight distribution and compensatory limping to avoid pressure on the affected toe, which can indirectly contribute to strain on the lower extremities.^[3] This altered walking pattern may lead to secondary musculoskeletal issues, such as knee or lower back pain, from prolonged abnormal loading on the joints and spine.^[4]

Causes and Risk Factors

Primary Causes

Hammertoe primarily develops due to biomechanical imbalances and external pressures that alter the normal alignment of the toe joints. These factors disrupt the equilibrium between the muscles and tendons responsible for toe movement, leading to a characteristic flexion deformity at the proximal interphalangeal joint.^[4] A key mechanism involves muscle and tendon imbalance, where the intrinsic muscles of the foot weaken relative to the stronger extrinsic muscles, particularly the flexor tendons. This imbalance causes the flexor tendons to overpower the extensor tendons, pulling the toe into a downward bent position while the proximal phalanx remains extended. Over time, this leads to contracture of the tendons and joint capsule, making the deformity rigid.^[2]^[4] Ill-fitting footwear is another direct cause, as shoes with narrow toe boxes or high heels force the toes into a flexed position, exacerbating pressure on the forefoot and promoting tendon tightening. High-heeled shoes shift weight forward, increasing the bend in the toes against the shoe's upper, which can initiate or worsen the deformity over prolonged use. Tight or pointed shoes similarly crowd the toes, preventing them from lying flat and contributing to permanent curling.^[3]^[1] Trauma, such as stubbing, jamming, or fracturing a toe, can also precipitate hammertoe by damaging ligaments, tendons, or the plantar plate, which disrupts the toe's structural stability and alignment. These injuries may cause immediate misalignment or lead to secondary muscle imbalances as healing occurs unevenly.^[1]^[13] Neurological factors contribute when conditions impair nerve signals to the foot muscles, resulting in weakness or atrophy that favors flexor dominance. For instance, Charcot-Marie-Tooth disease, a hereditary neuropathy, affects peripheral nerves and leads to progressive muscle imbalance, often manifesting as hammertoe deformities. Other neuromuscular disorders similarly alter muscle control, promoting the characteristic toe flexion.^[4]^[14]

Risk Factors

Hammer toe is more prevalent in older adults, as aging leads to weakening of the ligaments and muscles in the feet, which disrupts the balance necessary for proper toe alignment. This age-related decline increases susceptibility to deformities like hammer toe, with incidence rising notably in older age.^[2] Women face a higher risk of developing hammer toe compared to men, primarily due to prolonged use of ill-fitting footwear such as pointed-toe or high-heeled shoes that compress the toes and exacerbate muscle imbalances.^[1] Certain foot structures predispose individuals to hammer toe by creating inherent biomechanical imbalances. For instance, Morton's toe, where the second toe is longer than the big toe, shifts pressure unevenly during walking, increasing strain on the toe joints. Similarly, high arches (pes cavus) or flat feet (pes planus) can lead to excessive forefoot loading and muscle instability, further elevating the risk.^[3]^[15]^[1] Underlying medical conditions that impair circulation, nerve function, or joint integrity significantly heighten the likelihood of hammer toe. Rheumatoid arthritis contributes through chronic inflammation and joint erosion, leading to toe deformities. Diabetes is associated with peripheral neuropathy and poor circulation, which weaken foot muscles and promote abnormal toe positioning. Additionally, conditions like stroke can cause neuromuscular deficits, resulting in muscle imbalances that manifest as hammer toe.^[4]^[1]

Diagnosis

Clinical Examination

The clinical examination for hammer toe begins with a thorough visual inspection of the affected foot, where the healthcare provider observes the characteristic hammer-like deformity, marked by flexion at the proximal interphalangeal (PIP) joint and hyperextension at the metatarsophalangeal (MTP) joint, often most pronounced in the second toe.^[2]^[4] Redness, swelling, corns (hardened lumps on or between toes), or calluses (thickened skin areas) over the PIP joint or at the toe tip may also be noted, indicating pressure points from footwear or friction.^[16]^[17] Palpation follows to assess the joints and surrounding tissues, with the provider gently pressing along the toe to identify tenderness at the PIP or MTP joints, which can signal inflammation or irritation exacerbated by symptoms such as pain during movement.^[2]^[4] During this step, the flexibility of the deformity is evaluated by attempting manual correction; a flexible hammer toe can be passively straightened, whereas a rigid one resists extension due to fixed joint contracture.^[2]^[16] Callus formation is also palpated for hardness and location, often confirming dorsal pressure over the PIP joint.^[17] Range of motion tests are then performed to quantify joint mobility, involving passive and active extension of the toe against gentle resistance to determine the degree of contracture at the PIP and MTP joints.^[4]^[16] These assessments help differentiate early flexible deformities, which may respond to non-invasive interventions, from advanced rigid ones requiring more targeted management.^[2] Finally, gait analysis is conducted by observing the patient's walking pattern in both standing and ambulatory positions to evaluate biomechanics and any compensatory mechanisms, such as limping or altered weight distribution across the forefoot, which may arise from the toe's inability to bear load properly.^[4]^[16] This step reveals how the deformity impacts overall foot function during weight-bearing activities.^[2]

Imaging and Tests

Diagnosis of hammer toe primarily relies on clinical evaluation, but imaging modalities are employed to confirm the deformity, assess its severity, and exclude other pathologies. X-rays are the most commonly used imaging test, providing a clear visualization of bone alignment, joint angles at the proximal interphalangeal (PIP) joint, and any associated fractures, dislocations, or signs of arthritis such as joint space narrowing or osteophytes.^[18]^[19] Weight-bearing lateral and anteroposterior views of the foot are typically obtained to evaluate the metatarsophalangeal (MTP) joint extension and PIP joint flexion characteristic of hammer toe.^[20] Ultrasound serves as a non-invasive tool for evaluating soft tissue structures involved in hammer toe, including tendons, ligaments, and the plantar plate, which may be ruptured or inflamed contributing to the deformity.^[21] It is particularly useful in assessing dynamic abnormalities or soft tissue injuries not visible on plain radiographs, such as tendon subluxation or synovitis.^[22] Magnetic resonance imaging (MRI) is rarely indicated for straightforward hammer toe cases but may be utilized in complex scenarios to provide detailed images of nerve compression, muscle atrophy, or intra-articular pathology when symptoms suggest neurological involvement or when other imaging is inconclusive.^[19]^[21] To rule out differential diagnoses such as rheumatoid arthritis, which can mimic or cause toe deformities through inflammatory joint changes, laboratory tests including rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody assays are performed; elevated levels support an autoimmune etiology.^[23]^[24] Additional blood work, such as erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), may indicate systemic inflammation if rheumatoid arthritis is suspected.^[23]

Treatment

Conservative Treatments

Conservative treatments for hammer toe focus on non-invasive strategies to alleviate symptoms, particularly in the flexible stage where the toe can still be straightened manually. These approaches aim to reduce pressure on the affected toe, improve alignment, and enhance foot function without surgery, often providing relief for mild to moderate cases. Early intervention is key, as it can prevent progression to a rigid deformity.^[4] Footwear modifications are a cornerstone of conservative management, emphasizing shoes that accommodate the foot's natural shape to minimize friction and compression. Switching to shoes with a wide toe box allows the toes to spread naturally, reducing rubbing and pressure on the bent joint. Avoiding high-heeled or pointed-toe styles is recommended, as these exacerbate the deformity by forcing the toes into cramped positions. Low-heeled shoes with adequate depth further support proper toe alignment and weight distribution.^[18]^[3]^[2] Padding and orthotics provide targeted relief by cushioning high-pressure areas and correcting biomechanical imbalances. Over-the-counter toe pads or nonmedicated corn pads can be placed over the toe's apex or between toes to redistribute forces and prevent callus formation. Toe spacers or silicone props help maintain separation and straight alignment, with studies showing they effectively reduce peak pressure and pressure-time integrals on the second toe. Custom orthotic inserts, such as arch supports or metatarsal pads, address underlying foot mechanics like flat feet or high arches that contribute to the condition, often integrated into daily footwear for sustained support.^[2]^[18]^[25] Exercises target muscle flexibility and strength to counteract the toe's abnormal positioning. Simple stretches, such as gently pulling the toe straight with the hands or using it to pick up small objects like marbles from the floor, promote joint mobility. Strengthening routines, including towel scrunches where the toes grip and curl a towel toward the foot, enhance the intrinsic foot muscles. Regular performance of these exercises, typically 10-15 repetitions daily, can improve toe function and reduce associated pain like metatarsalgia. Physical therapy may guide these under supervision for optimal results.^[2]^[26] Medications offer symptomatic relief for pain and inflammation without addressing the structural issue. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are commonly used to decrease swelling and discomfort around the joint. Acetaminophen serves as an alternative for pain management when inflammation is minimal. These should be taken as directed, typically not exceeding 10 days without medical advice, to avoid side effects.^[3]^[27]

Surgical Options

Surgical intervention for hammer toe is typically reserved for cases where conservative measures fail and the deformity is causing significant pain, difficulty with footwear, or progression to a rigid state. Procedures aim to restore toe alignment by addressing tendon imbalances or joint contractures, often performed as outpatient surgeries under local or regional anesthesia. The choice of surgery depends on whether the deformity is flexible (correctable with manual manipulation) or rigid (fixed and non-correctable).^[2]^[4] For flexible hammer toes, tendon release or lengthening is a common initial approach to rebalance the forces acting on the toe. This involves surgically cutting or elongating the flexor digitorum longus (FDL) or flexor digitorum brevis (FDB) tendons at the proximal interphalangeal (PIP) joint to relieve the downward pull, sometimes combined with extensor tendon tenotomy to prevent recurrence. In some cases, tendon transfer redirects the flexor tendon from the bottom to the top of the toe for added stability. These procedures are minimally invasive and effective for early-stage flexible deformities.^[4]^[2]^[28] In semirigid or rigid deformities, joint resection arthroplasty removes the head of the proximal phalanx at the PIP joint, shortening the toe and allowing it to straighten while preserving some flexibility. This technique is particularly useful for elongated toes and may include ligament releases to facilitate alignment, often secured temporarily with Kirschner wires (K-wires). For more severe rigid cases, especially in multiple toes or when stability is paramount, PIP joint arthrodesis fuses the joint bones using pins, screws, or plates after resecting a small portion of bone, creating a permanent straight position but eliminating joint motion. Arthrodesis provides durable correction but is suited for patients who prioritize pain relief over toe flexibility.^[4]^[2]^[18] Recovery from hammer toe surgery generally spans 4-6 weeks, beginning with partial weight-bearing in a postoperative shoe or boot to protect the site. Splinting or taping maintains toe alignment, and pins or wires, if used, are typically removed after 2-4 weeks once healing progresses. Physical therapy is often recommended starting 1-2 weeks post-op to restore range of motion, strength, and gait, with full activity resumption in 6-8 weeks depending on the procedure. Patients should elevate the foot and limit strenuous activities to reduce swelling. Potential risks include infection (occurring in up to 5% of cases), recurrence of the deformity (reported in 10% or less), stiffness, or hardware complications, necessitating prompt medical follow-up if signs like increased pain or redness appear.^[2]^[4]^[28]

Prevention and Prognosis

Prevention Strategies

Preventing hammer toe involves adopting habits that minimize pressure on the toes and maintain foot flexibility and strength. Selecting appropriate footwear is a primary strategy, as ill-fitting shoes are a common modifiable risk factor. Shoes should provide at least half an inch of space between the longest toe and the end of the shoe to allow natural toe movement, feature a wide toe box to avoid crowding, and have low heels (ideally no higher than two inches) to reduce forward pressure on the toes.^[1]^[29]^[30] Opt for adjustable styles with laces or straps for a customizable fit, and purchase them later in the day when feet are typically more swollen for accurate sizing.^[1] Incorporating daily foot exercises helps strengthen the intrinsic muscles and improve flexibility, potentially averting toe deformities. Simple routines include toe curls, where one places a towel flat on the floor and uses the toes to scrunch it toward the heel, performed for 10-15 repetitions per foot to build toe grip strength.^[31] Manual toe stretches, gently pulling the affected toe straight with the hands while seated, can also maintain joint mobility; hold each stretch for 10-20 seconds, repeating several times daily.^[32] These exercises should be done consistently, ideally under guidance from a healthcare provider to ensure proper form. Early intervention for related foot issues, such as bunions or muscle imbalances, can halt progression toward hammer toe. Promptly addressing bunions with over-the-counter pads or cushions reduces adjacent toe pressure, while correcting gait imbalances through orthotics prevents compensatory toe curling.^[32] Regular foot inspections, particularly for those with predisposing conditions, allow for timely adjustments like custom inserts to redistribute weight.^[29] Lifestyle adjustments play a supportive role in prevention, especially for individuals at higher risk like those with diabetes. Maintaining a healthy weight alleviates overall foot stress by reducing load on the toes and joints during daily activities.^[33] For diabetics, consistent blood sugar control through diet, exercise, and medication minimizes neuropathy-related foot vulnerabilities that could contribute to deformities.^[34] Elevating feet periodically and incorporating low-impact activities like swimming further promote circulation and reduce swelling.^[29]

Prognosis and Complications

The prognosis for hammer toe is generally favorable when addressed early, particularly in flexible deformities where conservative treatments such as padded splints, orthotic inserts, and appropriate footwear can often alleviate symptoms and prevent progression without invasive intervention.^[2] In such cases, removing contributing factors like ill-fitting shoes may allow the toe to straighten naturally, leading to high resolution rates.^[3] For rigid hammer toes unresponsive to nonoperative measures, surgical correction, including tendon release or joint fusion, achieves pain relief in approximately 90% of patients and overall satisfaction in about 84%, though the toe may retain some stiffness post-recovery.^[35] Recurrence rates following surgery are up to 10%, with higher risks observed in the second toe and cases involving greater preoperative transverse plane deformity; addressing concomitant first metatarsophalangeal joint issues can reduce recurrence by nearly 50%.^[4] If untreated, hammer toe can progress from flexible to rigid, resulting in chronic pain, difficulty with shoewear, and gait alterations due to compensatory changes.^[4] Potential complications include the development of corns, calluses, or open sores from friction, which may lead to ulcers and subsequent bacterial infections, particularly in individuals with diabetes where neuropathy and poor wound healing exacerbate risks.^[31] Surgical interventions carry rare risks such as nonunion, infection, or numbness, but these are minimized with proper technique.^[35] Outcomes are influenced by timely diagnosis and patient adherence to treatment protocols, with flexible deformities responding best to early intervention; underlying conditions like diabetes or rheumatoid arthritis significantly worsen prognosis by increasing complication severity and recurrence likelihood.^[3]^[1]

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