What is a hammertoe?
A hammertoe is a retraction or clawing of the toes. The toes are named one to five with the big toe being one and the little tope being five.
The toes begin to bend and often pull back. The toes should ideally be straight with a possible very slight bend. This bend should be flexible or what we call reducible. You should be able to push the toes straight.
Typically the bend or retraction will be slight and gradual with increasing deformity and rigidity as time goes on.
Why do I get a hammertoe?
There are various causes of hammertoes, and often it may be a combination of many reasons.
- Genetics
- A bunion can lead the big toe to push the 2nd toe and eventually in a large bunion all the toes back
- Flat feet. The body may attempt to stabilise the flexible flat foot by grasping the ground.
- High arched feet. A high arch or supinated foot will develop retracted toes
- During sporting activities or just accidents, the ligaments and tendons that hold toes in place can be damaged and loses their ability to keep the toes straight
- Tight shoes
- Arthritis
Why do hammertoes become painful?
When a toe bends back, it tends to lose its flexibility and ability to move with pressure. When enclosed shoes are worn the prominent bones in the toes, protrude and rub on the shoes.
The rubbing produces friction that can be painful, especially if tight shoes are worn.
As the friction increases the body attempts to protect the exposed bones by developing hard skin called callus. This callus can then get compressed into a small area known as a corn.
The body is attempting to protect the toe from rubbing; however, it tends to make it worse, as you now have a hard lump over the exposed bone.
When the toes are markedly hammered, they can then push back on the joint that attaches the toes to the foot and can push this bone down resulting in pain on the ball of the foot.
As the toes become clawed and retracted the end of the toe can bend under leading to weight-bearing on the nail and not the cushioning fat pad. This can traumatise the nail leading to pain and a deformed thickened nail.
Can you reverse a hammertoe?
If you catch a hammertoe early enough then with a combination of interventions, sometimes you can straighten them.
This is discussed later; however, it must be borne in mind; this will take a combination of interventions and may take a long time.
What are the non-surgical treatments for hammertoes?
If you can start treatment on the hammertoe when it is mild and flexible then often a podiatrist can help you with:
- Various pads and moulded.
- Taping
- Strapping
- Insoles or orthotics with a metatarsal dome
- Exercises
- Gradual manipulation
Once you have an established hammertoe, it will not go away and will need to be managed to minimise pain. This is again can be managed by your podiatrist. It will involve:
- Cushioning foam pads
- Cushioning gel pads
- Moulded deflective silicone wedges
- Wearing deep, wide shoes
- Having corns and calluses regularly trimmed by your podiatrist
- Stretching shoes
Can I straighten hammertoes at home?
The answer to this is the same for above. In mild and flexible cases, you may be able to straighten them with the same non-surgical techniques mentioned above. It will involve a combination of treatments and may take a long time.
Hammertoe Surgery and Recovery
When do I need surgery?
Hammertoe surgery is typically carried out once the hammertoes become painful, trimming of corns does not relieve symptoms, wearing wide shoes or is starting to impact on your daily activities. Some people can also just get fed up with all the hassles of the daily routine of protecting the toes.
Hammertoe surgery in the past was painful and would involve long recuperation with “pins” sticking out of the toes.
With modern hammertoe surgery, this is now not the case, and hence it is usually best in a to correct the hammertoe before it damages the rest of the foot.
What surgery is carried out?
Modern hammertoe surgery has massively progressed to the stage where various options are available from simple soft tissue releases to complete realignment of multiple toe deformity.
- Soft tissue release. In the mild cases, if the deviation is minimal and flexible then under local anaesthetic and in the rooms, a small (minimally invasive/keyhole) puncture would is utilised, and the underlying contractures are released, and the toe manipulated straight.
- Removal of “bumps”. It is sometimes known as an exostectomy. Again, this can be done under minimally invasive/keyhole techniques. A simple puncture wound is carried out, and specially designed burrs are used to remove and prominences causing the problem.
- Minimally invasive correction of bone deviation. The same instrument as used above, yet with a different sized bur is utilised to cut bones allowing for correction. No stitching is required in most cases.
- Joint fusions. Even though the keyhole surgery can be used for most hammertoes in some situations, the joint may need to be fused. There is now, however, a marked improvement in the material used to allow fusion. The percutaneous “pins” (pins out the toes) are now no longer required to hold the toe straight while healing occurs.
- Many surgeons still rely on the technique of leaving pins out of the toes for four to six weeks. This technique is still prevalent, yet really is unnecessary now.
- If the toes do need to be fused absorbable pins, sometimes called dissolvable pins can be utilised. These allow for much less pain, shorter recovery and much less risk of complications, such as infection.
- This absorbable pin is also flexible and therefore once in it can be slightly bent to allow a more realistic and more comfortable toe as the pins sticking out of the toes, leave toes rigidly straight.
Is minimally invasive surgery/keyhole surgery appropriate for hammertoe surgery?
Yes, it is, most hammertoe surgery can now be carried out with keyhole surgery techniques. This allows for quicker recovery, less pain, fewer complications and NO pins sticking out of the toes.
What is involved in the recovery after hammertoe surgery?
If the hammertoe is mild and flexible, then the soft tissue release carried out in the rooms under local anaesthetic can be used. This has rapid recuperation. It involves taking it easy on the day of the procedure, via elevating the feet. A dressing is put on the toe and stays in place for approximately one week. This is then removed, and you tape the toe straight daily yourself for about two weeks. Most cases, no stitching required.
If one of the more involved procedures are required, as mentioned above, then surgery is carried out as a day surgery case, and there is no need for an overnight stay in the hospital. Hammertoe surgery allows patients to be on their feet immediately following the procedure. In these instances, patients are expected to wear a post-operative protective shoe over their bandaging to protect the surgical site. In the first 3-7 days, patients are expected to rest as much as possible even though they can walk to the toilet or to perhaps make a cup of tea or heat a meal. At your first post-operative review (approximately seven days following the procedure), the dressing is changed, and at two weeks this large dressing is replaced by a very small dressing following a daily saltwater soak. For most patients, a return to regular footwear occurs at about three weeks following the procedure, although this does vary from patient to patient.
When can I drive after hammertoe surgery?
For the softy tissue release, it is merely days. For the more involved cases, it is typically advised to avoid driving while the large dressing is on and you are in the post-op shoe. This will mean you should avoid driving for about 2-3 weeks. This is often for safety reasons.
Is hammertoe surgery painful?
One of the main improvements in hammertoe surgery is the marked reduction in pain. Pain is now controlled.
The incisions are tiny, and a lot less damage is done during the operation.
The advancements in medication also allow pain not be an issue at all now. Some patients may require more intervention, however many patients experience no pain after the surgery.
Will hammertoes come back after surgery?
Research has allowed us to know what works and what does not work. The aim of modern hammertoe surgery is to produce permanent results. The objective is to carry out the operation once and never again; however, there is always the very slight chance that the hammertoe may return.
What complications can occur?
Hammertoe surgery is very safe, and complications are now rare, although there are certain risks that patients must be made aware of, regardless of the rarity.
The risks of foot surgery are very similar to those risks posed by having other surgery, such as infection, unexpected pain, anaesthetic complications, and deep vein thrombosis.
Some specific to hammertoe surgery are delayed or non-union if fusion is necessary, contractures of the wound and unexpected scarring.
There are also risks associated with having certain medicines during and after your surgery, such as the possibility of nausea and vomiting.
There exist many very rare complications that can occur; these are very rare; however, they can occur.
Risks associated with surgery are explained to the patient during their pre-operative consultation. You will have every opportunity to ask as many questions as you like during the consultation.
Useful resources:
The Australasian College of Podiatric Surgeons
The American College of Foot and Ankle Surgeons