What is a Hammer Toe?
A hammer toe is a complex deformity involving any of the lesser toes (2nd, 3rd, 4th, 5th). 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 3 bones of the toe (distal, middle and proximal phalanges), the lesser toe joint (metatarsophalangeal joint), the 2nd, 3rd, 4th or 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 2nd toe.
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 is as rest and straight when standing. In other cases the toe is rigidly buckled and does not straighten.
The toe bone closest to the foot will flex upwards at its joint. The next toe bones with flex downwards at their joint. This combination of misaligned joints forms the buckling of the toe dand the prominence of the knuckle of the toe. With progression of the deformity, the ligaments holding 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 always worsen over time.
When just the tip of the toe flexed downward it is called a Mallet toe. This is a much less severe form of a hammer toe that is more easily accommodated or corrected.
What are the Symptoms of a Hammer Toe?
Not all hammer toes are painful. Someone may have a very severe hammer toe with no pain, while someone with a mild hammer toe can 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. 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 the skin) becomes inflamed from friction causing a bursitis. Numbness to the toe can develop with constant friction of the skin and nerve over the bump protrusion.
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 before them. If someone is destined to acquire a hammer toe over time, they will form a one or more. However, there are factors that can increase the speed and severity in which the deformity will develop. A high arched foot (pes cavus, supination) lends itself to an uneven pull of the tendons to the toe allowing for 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 hammer toe.
How is a Hammer Toe Diagnosed?
Diagnosis is simply achieved by the clinical examination and x-rays of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and evaluating their gait. Digital radiographs (x-rays) of the feet will be obtained in the office and reviewed with the patient. The positions of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated deformities.
How is a Hammer Toe Treated?
Dr. Soomekh educates that early diagnosis and treatment of hammer toes are the keys to successful treatment, faster recovery and painless lifestyle.
Conservative Treatment for 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 calluses 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-inflammatories 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 toes 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. Soomekh 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.
Is Hammer Toe Surgery Painful?
Considering surgery can be intimidating. Foot surgery including hammer toe surgery is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain. The goal of hammer toe surgery is to realign and straighten the toe, alleviate pain, allow a return to normal shoes, and allow a return to all activities. Most procedures allow for immediate walking and a return to work while wearing a special shoe or walking boot. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
Some Facts to Consider:
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 in order to formulate the proper procedure for repair. Dr. Soomekh 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 stepwise approach, evaluating the amount of correction achieved as each step is performed. The more the severe the deformity, the more steps are needed. In most cases in order to straighten toe and reduce the chance of recurrence, the toe bones will need to be fused (joined together).
Mild Hammer Toe: Arthroplasty
In some mild cases of hammer toe a simple removal of half the joint (arthroplasty) is sufficient. This procedure will allow for a faster recovery. However, there is an increased chance of recurrence and an unstable, “floppy” toe after surgery. When performed, an arthroplasty is usually reserved for the correction of a 4th or 5th hammer toe. This procedure used to be the gold standard for hammer toe correction, yet Dr. Soomekh’s research and experience has shown that a fusion of the toe joint achieves better long lasting results.
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. The joint is removed at the level of the knuckle giving room for the toe to straighten. The 2 bones (middle and proximal phalanx) are joined together by an internal screw. The bones are allowed to fuse into one. The screw holds the bones in their new corrected position while the bone heals. Once the bone heals, the screw is not needed and is generally not removed. If the toe is slightly elevated or deviated at the level between the toe and the foot, a small incision will be made at the level of the joint to release the tight ligaments bringing level. Dr. Soomekh will then close the skin using plastic surgery techniques.
Moderate to Severe Hammer Toe: 2nd, 3rd, 4th toes
When there is a more rigid deformity, the forces acting to deform the toe are stronger. This demands more steps to get the to straight. The steps mentioned above are performed. A longer incision is made over the toe and 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, the pressure at the level of the toe and the long bone is may be too great. The long bone may need to be shortened to decompress the joint and allow for the toe to float down in the joint. A precision cut is made at the head of the metatarsal (osteotomy). This bone is now slid back, shortening it under the original bone closer reducing the pressure in the joint. This bone is then stabilized with 1 small screw. The screw holds the bone in its new corrected position while the bone heals. Once the bone heals, the screw is not needed and is generally not removed.
Dr. Soomekh prefers to use internal fixation (a screw) into the toe in order to eliminate the need for a pin protruding from the toe during recovery. This lessens the chance of infection and pain during recovery.
When further correction is needed a tendon transfer may be warranted. One of the tendons that flexes the toe downward will be rerouted to the top of the toe act as an internal strap and brace, keeping the toe straight in the joint. In these cases, there is the need for use of a pin to support the toe during healing. This pin will need to protrude from the end of the toe and is removed simply in the office4 to 6 weeks after surgery. Dr. Soomekh will then close the skin using plastic surgery techniques.
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 eliminate half the joint by removing the head of the toe bone (proximal phalanx). Dr. Soomekh will close the special incision using plastic surgery techniques; when skin is brought together, the toe will rotate into a corrected.
When just the end of the toe is flexed downwards a simpler surgery is performed. A very small incision is made on the bottom of the toe. The tendon and ligaments that are tight, holding the toe down, are cut. Dr. Soomekh will then close the skin using plastic surgery techniques.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the toe specialists and toe surgeons in the Los Angeles area.