Hammer Toe

Hammer toe is a deformity affecting the middle joint of a toe, causing the toe to bend downward, resembling a hammer. This condition most commonly affects the second, third, or fourth toes and can occur in one or multiple toes simultaneously. Hammer toe develops gradually and, if left untreated, can become rigid and painful, limiting mobility and affecting daily activities.

Dr. Zackary Chua

Senior Consultant Orthopaedic Surgeon (Adult & Paeds)

MBBS (Aus) | MMed (Singapore) | MRCS (Glasgow) | FRCSEd (Orth)

Symptoms Causes Diagnosis Treatment Prevention FAQ

Symptoms of Hammer Toe

Patients with hammer toe may experience a range of symptoms that vary in severity depending on the progression of the condition.

Bent Toe Appearance

The affected toe bends downward at the middle joint, creating a hammer-like appearance. This deformity becomes more noticeable as the condition progresses.
Pain and Discomfort

Pain occurs primarily when wearing shoes, as the bent toe rubs against the footwear. The friction can lead to persistent discomfort while walking or standing.
Calluses and Corns

Friction between the toe and footwear often results in the development of calluses or corns on the top of the middle joint or at the tip of the toe. These hardened areas of skin can add to the pain experienced.
Inflammation

The affected joint may become red and swollen, particularly after prolonged periods of wearing restrictive shoes. The inflammation worsens with continued pressure.
Restricted Movement

As the condition advances, the toe becomes less flexible and more difficult to straighten. In severe cases, the toe can become completely rigid.

Causes and Risk Factors

Several factors contribute to the development of hammer toe, including anatomical predispositions and external influences such as footwear choices.

Muscle Imbalance

An imbalance between the muscles, tendons, and ligaments that control toe movement can cause the toe to be pulled into an abnormal position. This imbalance often results from underlying foot structure abnormalities.

Improper Footwear

Shoes with narrow toe boxes or high heels force the toes into a bent position, preventing adequate space for proper toe alignment. Prolonged use of such footwear raises the risk of developing hammer toes.

Toe Length

Individuals with a second toe longer than the big toe have a higher risk of developing hammer toe. The longer toe is more likely to be cramped in shoes, which can lead to deformity.

Foot Structure

Flat feet or high arches alter the pressure distribution across the foot, potentially leading to muscle imbalances that cause hammer toe.

Age

Hammer toe occurs more frequently with advancing age as tendons and muscles lose some of their elasticity and strength.

Trauma

Previous toe injuries, such as stubbing, jamming, or breaking a toe, can make that toe more susceptible to developing hammer toe.

Medical Conditions

Certain conditions, such as arthritis, diabetes, and neuromuscular diseases, can increase the likelihood of developing hammer toe due to their effects on joints and muscles.

Diagnostic Methods

Physical Examination

Assessment of toe position, flexibility, and pain points includes testing range of motion by manually straightening the toe. The presence of calluses, corns, or inflammation may indicate pressure points caused by misalignment. Evaluating the surrounding joints helps determine if other toes are affected or compensating for the deformity.
Medical History Assessment

A review of symptom onset, progression, footwear choices, previous injuries, and family history helps identify contributing factors and underlying conditions. Understanding daily activity levels and any aggravating factors provides insight into symptom severity and functional limitations.
Imaging Tests

X-rays provide a detailed view of bone structure, joint alignment, and the severity of deformity, guiding treatment planning. These images help assess joint damage and determine whether arthritis or other structural abnormalities are present. Additional imaging, such as MRI, may be recommended if soft tissue damage, such as tendon or ligament involvement, is suspected.
Gait Analysis

Observing walking patterns helps identify abnormal weight distribution, compensatory movements, and imbalances that may worsen the condition. Pressure mapping or video analysis may be used to assess how the hammer toe affects overall foot function.

Treatment Options

Management of hammer toe encompasses a spectrum of approaches ranging from conservative care to surgical intervention, tailored to the severity and impact of the condition.

Non-Surgical Treatment

Footwear Modifications: Switching to shoes with a broad, deep toe box allows adequate space for toes to lie flat. The appropriate footwear reduces pressure on the affected toe, preventing further irritation and allowing for more natural toe positioning. Soft, stretchable materials accommodate the deformity while providing the necessary support.
Orthotic Devices: Custom or over-the-counter shoe inserts help reposition the foot to relieve pressure on the affected toe. Orthotic devices provide proper arch support, helping to redistribute weight more evenly across the foot. Toe splints or straps may be used at night to stretch the contracted tendons and joints gradually.
Physiotherapy: Specific exercises strengthen the muscles controlling the toes and increase flexibility in the joints. Toe stretches, picking up marbles with toes, and towel curls help maintain or improve toe mobility. Regular therapy may slow the progression, particularly in flexible hammer toe cases.
Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) help reduce pain and inflammation associated with hammer toe. Topical pain relievers may be applied directly to the affected area for localised relief. Cortisone injections might be considered for persistent joint inflammation.

Surgical Treatment

Tendon Transfer: This procedure repositions tendons to rebalance the toe and restore alignment. The tendon responsible for pulling the toe into a bent position is redirected to the top of the toe, allowing it to lie flat. This technique is most effective for flexible hammer toes where the joint remains mobile and has not developed significant stiffness or arthritis.
Joint Resection (Arthroplasty): A portion of the joint is removed to create space for the toe to straighten. Tight tendons and soft tissues are released, and a small section of bone is excised from the bent joint to improve alignment. A temporary pin may be inserted to maintain proper positioning during healing. This procedure is commonly used for semi-rigid hammer toes where some movement is still possible.
Joint Fusion (Arthrodesis): The bones of the affected joint are permanently fused to keep the toe straight. During the procedure, cartilage is removed from the joint, and the bones are aligned and secured with metal pins or screws. Over time, the bones heal together into a single, solid structure, eliminating movement at the joint. This approach is typically recommended for rigid hammer toes where the joint has become fixed in a bent position and cannot be straightened without fusion.

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Prevention and Management

Maintaining foot health through preventive measures can significantly reduce the risk of developing a hammer toe or slow its progression. Wearing properly fitted shoes with adequate toe room allows toes to lie naturally flat. Regular toe exercises help maintain flexibility and muscle balance, while prompt attention to early signs of toe discomfort prevents the condition from worsening. For existing hammer toes, following the prescribed treatment plan and attending regular follow-up appointments enables monitoring of the condition and timely adjustments to the treatment approach. Addressing related foot problems, such as flat feet or high arches, through appropriate orthotic support helps prevent the muscle imbalances that lead to hammer toes.

Frequently Asked Questions (FAQ)

How long does recovery take after hammer toe surgery?

Recovery varies based on the procedure performed and individual healing. Most patients can transition back to regular footwear within 4-6 weeks, but full recovery may take 3-4 months. During the early stages, protective footwear or surgical boots help stabilise the toe while limiting weight-bearing as needed.

Can hammer toe return after treatment?

Recurrence is possible, especially if contributing factors, such as improper footwear, persist. Non-surgical treatments require ongoing preventive measures to maintain results. Even after surgery, a small risk of recurrence remains, though fusion procedures generally provide a lasting correction when paired with proper foot care.

Does hammer toe affect walking?

As hammer toe progresses, it can increasingly impact walking. In the early stages, discomfort is primarily linked to shoe pressure rather than movement. Over time, pain during walking may worsen, leading to changes in gait to avoid pressure on the affected toe. These compensatory movements can sometimes cause strain in the knees, hips, or lower back.

Dr. Zackary Chua

Senior Consultant Orthopaedic Surgeon (Adult & Paeds)

MBBS (Aus)|MMed (Singapore)|MRCS (Glasgow)|FRCSEd (Orth)

A distinguished Senior Consultant Orthopaedic Surgeon specialising in both adult and paediatric orthopaedic care.

Dr. Chua graduated from the University of Adelaide, Australia, with a Bachelor of Medicine and Bachelor of Surgery. He completed his Orthopaedic Specialist training under NUHS in Singapore in 2017.
In 2019, he was awarded the HMDP award, which enabled him to pursue a fellowship in Foot and Ankle Surgery at Oxford University Hospital NHS Trust in the UK.

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