In order to understand the multi-faceted aspects of hammer toes it is important to classify the the various types, and study them separately knowing that there are exceptions. 

 

Definition:

A hammer toe is a toe which is bent at the PIP-joint when walking.

There are two sorts of hammertoes:  functional and organic.

In the instance of the functional hammer toe, the toe is bent because of shoes that are too small. Without shoes the toe shows a normal outline.

The organic hammer toe keeps its bent shape without the shoe.

The organic hammer toe is divided into two sorts: a rigid and a mobile hammertoe.

In the instance of a rigid hammer toe the PIP-joint cannot be stretched.

In the instance of a mobile hammer toe the PIP-joint can be stretched completely.

 

The functional hammer toe.

This is a consequence of fashion, especially as regards ladies´shoes. The toes cannot be stretched out in the shoes and are forced into a flexion degree in the shoes.

Treatment:

There are several possibilities.

One is to explain the cause of the situation to the patient and then find out if the patient wishes to change his/her footwear and use appropriate broader shoes.

If this is the case reduction of the callosities, until they disappear gradually, by a podiatrist can be recommended. Often nothing further is necessary.

If the patient does not want to change his/her type of shoe, the use of a butterfly insole (link) with a rocker sole (link) must be recommended. In a few days this can make the patient free of symptoms, apart from the need for the reduction of callosities by the podiatrist.

 

The organically mobile hammertoe:

In this condition the toe can be straightened out completely, passively or actively.

Treatment:

If the patient is able to stretch the toe and make a plantar flexion of it, one can explain to the patient that practicing this will result in the pad being re-established and the symptoms disappearing, possibly by the use of a forefoot arch support.

Callosities can be reduced by a podiatrist.

Some mobile toes are too far bent for the patient to be able to start exercising the toe on his/her own or, for some other reason, demand surgical treatment. This means plantar flexor tenotomy on a level with proximal phalangs and perhaps dorsal tetonomy at the MP-joint.

Simple pellotte is then often sufficient.

 

The organic, rigid:

This is often the result of a prolonged flexion condition without any effort to stretch the toes. Some neuro-biological conditions will also bring about flexion conditions, which develop gradually into a rigid state. Carchot-Marie-Tooth, disseminated sclerosis, diabetes mellitus and neurological traumas to mention a few.

 

Patophysiology:

The permanently flected toe develops destruction of the plantar pad and callosities develop. In addition there are some patients having troubles on the dorsal side of the PIP-joint. Some patients with hammer toes, especially the second toe develop hallus valgus at the same  time. 

Circulatory  disturbance is found in some patients.

 

Treatment:

Can be conservative treatment with a butterfly insole and a rocker sole. This will be a specially attractive  solution for elderly people, where many toes being involved or where there are circulatory problems of a more difficult kind. In a few especially selected cases

with  concomitant DM or with so much latus in the foot that ordinary shoes cannot give enough  room for the foot, orthopædic footwear can be recommended. The callosities are often somewhat permanent  but can be treated by a podiatrist. This applies especially to DM patients Surgical treatment will always have to be a PIP-joint resection combined with a dorsal capsulotenotomy at the MP-joint. These patients can often later be given a simple forefoot pelotte.

 

Methods of operation:

The PIP-joint resections can be performed to different principles.

A: One method means that one aims at making the distal end of proximal phalangs and the proximal end of the second phalangs meet, so that an ossicle is made.

B:  The other method consists of preventing the two ends from meeting and in this way creating a dangle toe. Both methods have advantages and disadvantages, of which the patient ought to be informed  before choosing the preferred method..   

A:  The first method is the better looking cosmetically, but “recurrence” is not unknown, especially where no dorsal capsulo-teno-tomi is made.

B:  The other method is cosmetically plain and can create some inconveniences if too much ossicle has been resected so that the toe remains a dangle toe (otherwise the flexor tendon retracts the toe so that it becomes semi-stiff. I consider it the better one as the functional result is perfect. With dorsal capsulo-teno-tomies it is important to cut m. ext. dig. brevis, as otherwise the result will easily be a toe that later will turn upwards.

 

Forefoot fall – the consequence of a hammer toe:

The shape of the hammertoe causes by the law of the parallelogram of  forces an intensified pressing down of the metatarsal head corresponding to the toe in question. The effect of this will be that the fat pad under the metatarsal head will be pressed up along the  sides of the metatarsal head. The consequences are a reduction of the distance from the metatarsal head so that only the skin separates them from the ground. When this has been going on for some time the skin cells begin to multiply with the effect of painful callosities.. The other inevitable painful effect is compression/strain problems with pains dorsally at the PIP-joint.

This simple strain can either be set right through shoes, correction of shoes or handmade shoes.

The alternative is an operation.