What are the treatment options for hammer toes?

Treatment Options for Hammer Toes

For hammer toe deformities, treatment should begin with conservative measures, progressing to surgical interventions only when conservative treatment fails, with digital flexor tenotomy being strongly recommended for neuropathic toe ulcers with flexible toe deformities.

Conservative Treatment Options

Footwear Modifications

• Wear properly fitting shoes with a wide toe box to accommodate the deformity 1
• Avoid thin-soled slippers, walking barefoot, or wearing socks only 1
• Consider shoes with rocker and cushioned soles for symptom relief 2
• For patients with foot deformities or pre-ulcerative lesions, extra-depth shoes may be necessary 1

Orthotic Devices

• Toe silicone or semi-rigid orthotic devices can help reduce excess callus on toes 1
• Metatarsal pads placed 6.5mm proximal to the metatarsal head can reduce peak pressures by 33% 2
• Custom-made insoles can further reduce metatarsal head pressures by 23% 2
• For patients with a history of plantar ulcers, therapeutic footwear with demonstrated plantar pressure-relieving effect (30% relief compared to standard footwear) is strongly recommended 1

Padding and Protection

• Felted foam in combination with appropriate footwear can be used when other biomechanical relief options are not available 1
• Apply topical emollients to periungual folds and nail plate daily to promote healing and prevent infection in cases with nail involvement 3

Surgical Treatment Options

For Flexible Hammer Toe Deformities

1. Digital Flexor Tenotomy:
   • Strongly recommended as first-line treatment for neuropathic plantar or apex ulcer on digits 2-5 with flexible toe deformity 1
   • Highly effective with 97% healing rate in a mean of 29.5 days 1
   • Can be performed in outpatient setting with minimal resources 1
   • Few complications reported, making benefit-to-risk ratio favorable 1
   • Particularly indicated when conservative treatment fails in high-risk patients with diabetes, hammertoes, and either pre-ulcerative signs or ulcers on the distal toe 1

For Rigid Hammer Toe Deformities

1. Proximal Interphalangeal Joint Arthrodesis:

   • Provides reliable fixation with high fusion rates (83-98%) 4
   • High patient satisfaction rates (83-100%) 4
   • Indicated for fixed-flexion deformity that fails conservative treatment 4
   • Can be performed with various fixation methods (K-wires, screws, bioabsorbable pins, or intramedullary implants) 5, 4

2. Arthroplasty:

   • Resection of the head of proximal phalanx 6
   • Allows some retained motion but may lead to deformity and pain over time 4
   • Success rates approach 90% for pain relief 5

3. Subtraction Osteotomy:

   • Distal subtraction osteotomy of the proximal phalanx neck 6
   • Preserves the integrity of the proximal interphalangeal joint 6

   • 90% excellent and good results reported 6

4. Other Surgical Options:

   • For complex cases: consider metatarsal head resection, joint arthroplasty, or osteotomy 1, 7
   • For diabetic patients with recurrent plantar forefoot ulcers: Achilles tendon lengthening may be considered 1

Treatment Algorithm

1. Initial Assessment:

   • Determine if hammer toe is flexible or rigid
   • Assess for pre-ulcerative lesions, ulcers, or calluses
   • Evaluate for neuropathy, especially in diabetic patients

2. For All Patients:

   • Begin with proper footwear modifications and orthotic devices
   • Monitor for symptom improvement

3. If Conservative Treatment Fails:

   • For flexible deformities with ulcers (especially in diabetic patients): Digital flexor tenotomy
   • For rigid deformities: Consider arthrodesis, arthroplasty, or osteotomy based on severity and patient factors

4. For Diabetic Patients at Risk of Ulceration:

   • Provide integrated foot care including professional foot treatment, adequate footwear, and education
   • Monitor every 1-3 months for high-risk patients 1
   • Consider temperature monitoring to detect early inflammation 1

Important Considerations and Pitfalls

• Surgical intervention should only be considered after conservative measures have failed
• For diabetic patients, always assess for neuropathy and vascular status before any intervention
• Avoid excessive bone resection during surgery which can lead to cosmetically undesirable short toes 4
• For severe deformities, K-wire fixation is often preferred as excessive stretching of neurovascular bundle can lead to toe compromise 4
• Post-surgical care requires continued use of appropriate footwear and possibly activity modifications for several weeks 4