What to Do About That Hammer Toe

While hammer toes aren't always easy to fix, they are typically easy to spot. A hammer toe causes the middle part of your toe to bend upward and the end of your toe to flex downward, creating a shape that vaguely resembles a hammer—hence the name. It often develops on the second, third, or fourth toe, and there is frequently a callus or corn on top of the affected joint because of the way it rubs against your shoe. While most hammer toes occur on adult feet, they can sometimes affect children as well. They may cause pain or discomfort when you walk.

How do they develop, you ask? Well, each of the lesser toes has three bones (phalanges) and three joints. Medically speaking, a hammer toe occurs when there is an extension (upward) contracture of the joint at the ball of the foot (the metatarsophalangeal joint) and a flexion (downward) contracture of the middle toe joint (the proximal interphalangeal joint), most often due to an imbalance in the muscles of the toes or feet or wearing shoes that don't fit properly. 

Muscles in the lower leg and within the foot contribute to foot stability and function, and imbalances in the strength of these muscles can cause hammer toes to develop. These muscle imbalances are most often due to hereditary leg and foot structure but can occur secondary to neurological damage, such as seen after a stroke or spinal injury. Diabetes, which can cause nerve damage affecting leg muscle strength, is an example of a condition where hammer toes can develop.

Hammer toes that are just starting to develop, such as with children or young adults, are usually flexible, meaning the toe can be manually pulled straight. But the longer a hammer toe has been present, the more likely it is to be rigid, or non-reducible. This is because bone and soft tissue changes have occurred over time.

There is controversy over how much of a role shoes play in the development of hammer toes and other foot deformities, such as bunions. It is unlikely that shoes, such as high heels, are complete to blame for toe problems. This is evident because we see hammer toes affect people who wear even the most ergonomic shoes. Also, not everyone who routinely wears high heels will develop hammer toes. However, high heels or tight shoes do contribute to hammer toes and can aggravate them, especially if one has a foot type that is prone to toe deformities. Not only do high heels cramp toes and cause rubbing, but they also create muscle imbalances when worn, putting stress on the toes resulting in toe contractures.

For some people, hammer toes may just be a cosmetic concern, if they are not causing any pain or if they are not the result of a more complex problem, such as arthritis. But often, a hammer toe is associated with pain or other problems, which may require podiatric care. Potential problems or associated conditions include:

• Painful corns on the top of the toe or in between toes
• Corns or calluses under the ball of the foot
• Pain in the ball of the foot - also known as metatarsalgia
• Arthritis pain in the joints of the toe
• Rheumatoid Arthritis - An autoimmune disease and less common form of arthritis that can result in toe deformities
• Bunion - A misalignment of the big toe or pinkie toe that causes a characteristic bump on the side of the foot
• Flat Feet
• Knuckle Pads - Thickened and sometimes discolored areas of skin over the joints of the toe in response to friction. They appear smoother than a corn or callus.

Hammer toes that are flexible and can be manually pulled straight as described above may improve with specific exercises, which counteract the muscle imbalances that contribute to the deformity. These exercises target the extensor muscles, which pull the foot upward. Exercises that involve pulling the foot upward against resistance will target the extensor muscles.

Custom-made orthotics, which are usually obtained from a podiatrist, can also help counteract the imbalances that lead to hammer toes and other toe deformities. These are arch supports that are custom-made to an individual's foot. Some podiatrists and other foot or orthotic specialists add heel or arch wedges to over-the-counter arch supports, which can help improve toe position while walking.

These methods can improve a hammer toe's appearance and related symptoms, but may not always stop them from getting worse. Heredity plays a strong role in the appearance of our feet, no matter how well we take care of them. Over-the-counter toe splints and other devices for hammer toes are easily available and are helpful for reducing shoe friction, which can lead to pain.

Rigid hammer toes can be corrected surgically using procedures that remove bone and soft tissue to realign toes. Surgical correction is usually reserved for cases where conservative measures fail to relieve symptoms, or if the hammer toe is causing secondary problems, such as skin wounds.