Hammer toe

People with hammer-toe deformity notice worrying changes in the appearance of their toes. The affected toe remains bent. Initially the bend is flexible and reversible; over time it becomes rigid, fixed, irreversible and non-correctable.

A corn forms at the apex of the bend (the proximal interphalangeal joint), eventually causing severe pain and friction against footwear. Constant irritation from the inside of the shoe may cause chronic inflammation and even an open wound with the interphalangeal joint visible.

In severe deformities, changes may develop in other forefoot joints, for example the metatarsophalangeal or distal interphalangeal joints.

Many factors can lead to hammer-toe deformity:

• Sex: women are affected much more often than men
• Age: the deformity usually appears after the age of 50
• Inappropriate footwear. People who wear shoes that are narrow at the front are particularly at risk of developing the deformity
• Excessive toe length, especially of the second toe
• Excessive length of the metatarsal bones, mainly the second and less often the third compared with the first, known as Greek foot
• Hallux valgus deformity
• Cavus foot
• Rheumatic diseases, for example rheumatoid arthritis
• Hindfoot deformities caused by neuromuscular disorders, for example in Charcot–Marie–Tooth disease, Friedreich ataxia, cerebral palsy or multiple sclerosis
• Weakening of the posterior tibial and peroneus longus muscles
• Contracture of the gastrocnemius muscle

Conservative treatment of hammer toe

Specialist orthoses can be helpful in conservative treatment.

For severe deformities, orthopaedic footwear should be considered.

It is particularly important to prevent open abrasions on the dorsum of the bent proximal interphalangeal joint by wearing shoes with high, wide toe boxes.

Surgical treatment of hammer-toe deformity 

Surgery should be considered for large deformities that do not respond to conservative treatment.

Different surgical methods are used depending on whether the deformity is flexible and correctable or fixed and rigid.

For flexible, correctable deformities, soft-tissue procedures are used, such as:

• Girdlestone procedure using the flexor digitorum longus tendon
• Pisani procedure using the flexor digitorum brevis tendon

For rigid, non-correctable deformities, bone surgery is required in addition to the above soft-tissue procedures. The most common procedures are:

• Minimally invasive surgery (MIS)
• Arthrodesis, that is, fusion of the toe’s proximal interphalangeal joint

If several toes are affected or the deformity accompanies other foot deformities, surgery is performed in a single session.

After surgery, the patient walks in postoperative footwear for 5 weeks.

After this time, the patient begins wearing regular footwear, which must be somewhat roomier and have a flat sole.

Rehabilitation is an important element supporting rapid recovery after hammer-toe surgery. To be effective, it should be based on the following principles:

• the patient’s condition should be assessed
• Individual recommendations should be prepared for postoperative treatment of hammer toes
• therapy should be adapted to the patient’s abilities

Individual exercises with the patient aim to:

• improve the range of motion in the joints of the operated lower limb
• improve proprioception
• improve neuromuscular coordination
• Reduction of swelling (soft-tissue work, lymphatic massage, kinesiotaping)
• correct gait and faulty movement habits
• physiotherapy

HalluxmedAllow YouTube and play video

Playing the video allows a connection to YouTube and data processing by that provider.

In foot surgery, ensuring a pain-free operation and minimising postoperative pain have always been major challenges.

It is commonly believed that recovery after foot surgery, especially hallux surgery, is very painful.

There are many options for anaesthesia during procedures on the foot.

Modern anaesthesiology aims, wherever possible, to use regional anaesthesia techniques – from central blocks such as spinal and epidural anaesthesia, commonly known as lumbar anaesthesia, to peripheral nerve blocks at various levels performed under ultrasound guidance, especially when operating on one foot.

The possibility of using a particular type of anaesthesia depends mainly on the extent of surgery and any coexisting conditions.

The final choice of anaesthesia is agreed with the patient during the preoperative assessment interview.

Using ultrasound in anaesthesiology to perform peripheral nerve blocks has enabled highly precise regional anaesthesia.

Our many years of experience have changed our perioperative approach, both to anaesthesia itself and to the postoperative period.

For foot surgery, peripheral nerve anaesthesia, known as an ankle block, means injecting a local anaesthetic around the nerves at the appropriate level.

These anaesthetics are highly precise because the nerves responsible for pain sensation are clearly visible on ultrasound and medication delivery is fully controlled.

This can substantially reduce or even eliminate the need for pain medication early after surgery.

For many patients, one of the most important advantages is that sensation above the knee is preserved in the operated leg and, most importantly, lumbar anaesthesia is avoided, which patients do not always accept.

Another important advantage is that walking can begin very soon after the procedure.

During the postoperative period, administering pain medication at regular intervals under ultrasound guidance around the nerves responsible for pain enables patients to pass through this period as comfortably and painlessly as possible.