Podiatry Insights - Hammertoes

With changes in lifestyles, footwear and activities of daily living, foot and lower limb structural abnormalities are becoming more prominent.

This increase can also be attributed to the fact that people are now more than ever before, conscious of their feet and the shape that its takes or forms over time.

A common problem that presents to podiatry clinics is one of malalignment of the lesser toes. The most often of these is an affliction referred to as ‘hammer-toeing’ of the toes.

A hammertoe deformity is one that is characterised by a retraction of the middle toe joints (dorsiflexed) whilst the furthest most part of the toe is curled downwards (plantar flexed). The result of which, is a raised, triangular styles middle portion of the toe joint which has a tendency to form pressure sports due to shoe pressure and a front part of the toe that is prone to callousing and corns. Hammertoes are not life threatening, however if left untreated may get worse and more debilitating over time.

Hammertoes have a number of potential causes which are listed below. It is important to realise however, that this deformity can be the result of a single factor or a combination of both intrinsic and extrinsic factors. Some common causes of hammertoes includes:

• Joint arthritis (typically osteoarthritis, however rheumatoid arthritis can also be a culprit).
• Tight or poorly fitting footwear.
• A structurally longer toe. This usually occurs at the second digit but can affect any 5 digits.
• Sidewards pressure from a bunion deformity.
• Traumatic injury to the toe.
• Joint instability or an overly flexible foot.
• Pre-existing biomechanical foot factors such as an overly high arch.
• Generalised leg muscle tightness.

Most patients will present to a podiatry clinic with complaints of irritation along the top (dorsal) surface of their toes. This often corresponds to areas of pressure or rubbing along the surface of the shoe. Pressure induced irritation can often be due to callousing, corns or inflamed skin. Secondly to this, people with this deformity can present with concerns about the general appearance of positioning of their toes or pain along the balls of their feet which may be a secondary symptoms from the altered biomechanics caused by retracted toes. This discomfort may then result in an altered gait cycle which may impact on joints further up the chain including knees, hips and lower back.

In order to provide a bit of guidance with regards to treatment options available, below are a few options which may work to alleviate either the symptoms associated with hammertoe, or help correct the hammertoe deformity itself.

• Modification of current footwear to more accommodating, deep toe boxed varieties.
• Splinting or strapping of toes in a ‘straightened’ position to reduce the deformity. This will only be possible is the issue is a ‘soft tissue’ deformity and not a rigid version of the problem.
• Ice and anti-inflammatory medication may help with pain.
• Padding or offloading of sensitive pressure spots. This may often be done using semi-compressed felt.
• Removal of secondary corns or callouses which may be contributing to discomfort.
• Corrective orthotic devices which may reduce associated symptoms by correcting contributing biomechanical factors.
• Corticosteroid injections.
• Surgical correction of the hammertoe. If the deformity is ‘soft’ and reducible, the procedure may involve tendon lengthening/cutting and joint re-alignment. If rigid, or affected by osteoarthritis, an arthroscopy may be warranted followed by some changes to the bony structures to ensure correct alignment and salvaging the maximum amount of range of motion of the joint. Most surgical procedures however will usually follow number of weeks of rest, rehab and requires the patient to wear a surgical boot/shoe prior to commencing physical therapies.

There is no magic bullet to dealing with hammertoes. This is why it is essential to have any concerns about your foot, toe or lower limb alignment checked out by a podiatric specialist who can guide you as to the best and most appropriate treatment protocol for your presenting complaint.

By Anel Kapur

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