From the Guidelines
For individuals with diabetes and non-rigid hammer toe, digital flexor tendon tenotomy is a recommended treatment option to prevent foot ulcers and reduce excess callus, as it has been shown to have moderate desirable effects and small undesirable effects 1.
Treatment Options for Hammer Toe
Treatment for hammer toe can vary depending on the severity and the presence of underlying conditions such as diabetes. For mild cases, conservative treatments are often the first line of approach. These include:
- Wearing properly fitted shoes with a wide toe box to reduce pressure on the toes
- Using cushioned pads to alleviate pressure on the affected toe
- Performing toe exercises, such as picking up marbles with the toes, to strengthen the foot muscles
- Over-the-counter pain medications like ibuprofen (400-800mg three times daily) or acetaminophen (500-1000mg every 6 hours) to manage discomfort
- Custom orthotic devices to redistribute pressure and provide support
Surgical Interventions
For flexible hammer toes, manual stretching and splinting devices worn at night can help maintain proper alignment. However, when conservative measures fail or for rigid hammer toes that cannot be straightened manually, surgical options may be considered. These include:
- Tendon transfers
- Joint resection (arthroplasty)
- Fusion procedures (arthrodesis) Surgery typically involves a 4-6 week recovery period with limited weight-bearing. Early intervention is crucial as hammer toes can progressively worsen over time due to muscle imbalances that cause the toe joints to contract and eventually become rigid, making non-surgical treatments less effective for advanced cases.
Considerations for Individuals with Diabetes
For individuals with diabetes, particularly those at risk of foot ulceration, the approach may differ. Digital flexor tendon tenotomy is specifically recommended for people with diabetes who have a non-rigid hammer toe with nail changes, excess callus, or a pre-ulcerative lesion on the apex or distal part of the toe, as it can help prevent foot ulcers 1. Additionally, orthotic interventions such as toe silicone or (semi-)rigid orthotic devices can be considered to reduce excess callus on the toe 1. The decision for surgical intervention, such as digital flexor tenotomy, should be made after a full evaluation of non-surgical treatment options by an appropriately trained healthcare professional, considering the potential benefits and risks, including the possibility of transfer lesions or non-healing of the surgical incision in individuals with poor arterial supply to the foot 1.
From the Research
Treatment Options for Hammer Toe
- Conservative management is often attempted before surgical indication, and includes shoe modifications and the application of orthoses to alleviate symptoms 2
- Proper footwear includes rocker and cushioned soles shoes, a wide toe box, proper length, and a lowered heel, eventually combined with the placement of a felt pad 2
- A custom-made silicone orthosis applied at the second digit metatarsophalangeal (MTP) joint in a hammer or claw toe seems to reduce mean peak plantar pressure in the rigid stage of deformity but not the flexible one 2
- Metatarsal pads can also be used to diminish peak pressures, with a 12.5-mm insole further reducing peak metatarsal head pressures by 23% compared with a 2.5-mm insole 2
Surgical Treatment Options
- Proximal interphalangeal joint arthrodesis is a common operative method of treatment of hammer toe, which involves resection of the articular surfaces to allow osseous apposition and fixation with a smooth Kirschner wire 3
- Alternative surgical treatments include proximal interphalangeal arthroplasty, soft-tissue capsulotomy, extensor tendon lengthening, and amputation 3
- Arthrodesis provides less painful and more reliable fixation as well as equal outcomes compared with other operative techniques, with patient satisfaction rates after this procedure being high, with pain relief in up to 92% of patients 3
- The use of absorbable pins, such as the poly L-lactate 2-mm absorbable pin, has been shown to result in minimal coronal angulations, no soft corns, high fusion rates, and patient satisfaction 4
- Intramedullary fixation systems have also been developed for the treatment of hammertoe deformity, with satisfactory radiographic alignment and low complication rates 5
Postoperative Care
- Patients are often able to return to regular activity at 6 weeks postoperatively, but may experience persistent pain or swelling in the toe 3
- Wide shoes and activity modifications are frequently continued for several more weeks postoperatively, and some patients may benefit from formal physical therapy and at-home rehabilitation 3
- Avoiding vascular compromise by ensuring adequate resection of bone at the proximal interphalangeal joint is crucial, and excessive osseous resection can lead to a cosmetically undesirable short toe 3