Hammer Toes: Throw the kitchen sink at them

A hammer toe is one of the more common types of foot problems. A hammer toe is when (usually) one toe is drawn up and backwards, making the first joint in the toe stick up above the rest of the other toes. Technically, the definition of a hammer toe is: “A sagittal plane deformity of the toe where the proximal interphalangeal joint (PIPJ) is flexed, the distal interphalangeal joint (DIPJ) is in a neutral or extended position and the metatarsophalangeal joint (MPJ) is neutral or dorsiflexed.” The most common symptom of a hammer toe is a painful corn can form on the top of the prominent joint (from pressure between the toe and the shoe) or on the end of the toe (from pressure between the toe and the ground).

Causes of Hammer Toes

The exact cause of a hammer toe is not totally clear, but it is clear that there are a number of factors that can increase the risk for a hammer toe:

Inappropriate footwear. Footwear that has a narrow toe box, has an inadequate depth of toe box, or is too short or too small will try and push the toe into the hammered position, especially if the second toe is longer.
Hammer toes are associated with bunions (hallux valgus) and this is assumed to be because the deviation of the big toe makes the joints in the second toe unstable, so hammering occurs as a result of that instability.
There is certainly a familial predisposition or inherited factors involved as they do tend to run in families
Hammer toes are more common in some neuromuscular disorders (eg Charcot-Marie-Tooth disease) due to selective involvement of different muscles affecting the ‘balance’ of the toe.
Instability of the foot during propulsion leading to what is called a flexor stabilization could be most common cause of a hammer toe. This is when the small muscles in the arch of the foot and ball of the foot loose their ability to stabilize the toe on the ground, so it easily moves into a hammered position.
A shorter or plantarflexed metatarsal can also result in a hammer toe as when a metatarsal plantarflexes, the toe extends, creating the hammered position (the opposite also happens if the metatarsal is dorsiflexed).

Consequences of Hammer Toes

There are three consequences of hammer toes:

First, they do not look good!

Second, there is going to a be a problem getting shoes that have a deep enough toe box area to fit the foot into with comfort.

Third, they are going to hurt. Painful corns can develop on the top of the toe from pressure between the toe and the shoe. Painful corns can also develop on the end of the toe from pressure between the toe and the ground. These corns or pressure areas can also break down into ulcers that may get infected which can be particularly serious if you have diabetes. A metatarsalgia can also develop on the ball of the foot under the metatarsal head from excessive pressure.

Treatment of Hammer Toes

The first thing to do is relieve the pain with conservative approaches:

Get into wider and deeper shoes. Avoid shoes that are too short, too narrow and not deep enough. It does not matter how much you paid for the shoes, it matter how well they are fitted.
The corns and calluses can be reduced by a podiatrist or other method – they will tend to come back again as the pressure on the hammer toe is still there. They do not come back as the “roots” were not removed. However, this regular debridement of the corns can give a lot of relief.
Corrective or protective padding can be used to off load pressure from the painful areas
Splints (eg the Budin Toe splint) or toe correctors can be used to move the toe into a more corrective position.
Podiatrists also have a range of other types of devices that they can use such as the silicone orthodigital devices that can be custom molded to correct and offload the toe.

Surgery is an option if these conservative approaches to a hammer toe do not help. There are so many different surgical techniques that can be used for a hammer toe and this is going to depend on the exact nature of the hammer toe, the health and viability of the tissues, the degree of deformity, how flexible or rigid it is and the personal preferences of the surgeon. This different surgical approaches include a fusion of the joints in the toe; a dorsiflexion osteotomy of a plantarflexed metatarsal; may be included with a surgical correction of a bunion; transfer of tendons to self correct the alignment; removal of bony prominence(s) causing the high pressure such as a resection of the proximal interphalangeal joint; there may only be soft tissue procedures to release contractures. Some of the techniques may involve the use of a K-wire insertion to fix the toe in better alignment.

What about exercises for a hammer toe?
It is not uncommon to come across recommendations for different exercises to help hammer toes. While anything to keep the toe mobile or flexible is a good thing and will probably result in a better long term outcome, the chances of success with using exercises to correct a hammer is low. A lot of effort will be needed for what may only be a minimal or no gain. If you look at the list of factors above that increase the risk for a hammer toe, the mechanism by which exercise can change most of those is non-existent.

Some exercises advocated for a hammer toe may actually make it worse. Some of the small muscles in the arch and ball of the foot attach to the bones in the toes and they function to hold the toe on the ground. However, when the toe hammers, the angle of pull of those tendons changes to being above the joint axis, so when they contract, they further hammer the toe rather than hold the toe on the ground. Pretty pointless doing exercises to make theses muscles stronger when they do that.

My Personal Opinion on Hammer Toes

If it was my toe and I was healthy, I would not hesitate to have surgery on a hammer toe.
I would not be wasting my time on doing exercises for this (I do strongly advocate exercises for other types of foot problems, but not this one).