What is the treatment for hammer toe?

Hammer Toe Treatment

For symptomatic hammer toe, start with conservative management using proper footwear with adequate toe box depth, toe orthoses (silicone or semi-rigid devices), and professional callus debridement; if conservative treatment fails after 3-6 months, proceed to surgical correction with proximal interphalangeal joint arthrodesis for rigid deformities or digital flexor tenotomy for flexible deformities, particularly in diabetic patients. 1, 2, 3

Conservative Management (First-Line)

Footwear Modifications

• Prescribe extra-depth shoes or custom-made footwear to accommodate the hammer toe deformity and reduce pressure on the apex of the toe. 1
• Ensure minimum 5mm additional depth compared to standard footwear to prevent dorsal toe irritation. 1
• The footwear must fit properly and accommodate the shape of the foot without creating new pressure points. 1

Orthotic Interventions

• Consider prescribing toe silicone or semi-rigid orthotic devices to reduce excess callus formation on the hammer toe. 1
• These devices help redistribute pressure away from the deformed joint and prevent skin breakdown. 1

Professional Foot Care

• Provide appropriate treatment for excess callus, pre-ulcerative lesions, and nail changes through regular professional debridement. 1
• This is particularly critical in diabetic patients at risk for ulceration (IWGDF risk 1-3). 1

Exercise Programs

• Consider an 8-12 week foot-ankle exercise program under professional supervision to strengthen intrinsic foot muscles and improve toe alignment. 1
• Continue exercises long-term to maintain benefits and reduce progression of deformity. 1

Surgical Management (When Conservative Treatment Fails)

For Flexible (Non-Rigid) Hammer Toe

Digital flexor tenotomy is the procedure of choice for flexible hammer toe with nail changes, excess callus, or pre-ulcerative lesions, particularly in diabetic patients. 1

Evidence Supporting Flexor Tenotomy:

• Achieves 92-100% healing of distal toe ulcers in mean time of 21-40 days with low complication rates. 1
• Can be performed in outpatient setting without need for subsequent immobilization. 1
• Does not negatively affect foot function and has very few reported complications. 1
• This procedure is particularly valuable for recalcitrant toe ulcers that fail conservative treatment. 1

For Rigid (Fixed) Hammer Toe

Proximal interphalangeal joint arthrodesis is the gold standard surgical treatment for rigid hammer toe deformities. 2, 4, 3

Surgical Technique:

• Resection of articular surfaces at the proximal interphalangeal joint to allow osseous apposition. 3
• Fixation with Kirschner wire, permanent internal fixation devices, or intramedullary implants. 4, 3
• Address dorsal contracture of metatarsophalangeal joint with Z-lengthening of extensor tendon if needed. 3
• Release collateral ligaments if angular deformity persists. 3

Expected Outcomes:

• Osseous fusion rates of 83-98%. 3
• Pain relief in up to 92% of patients. 3
• Patient satisfaction rates of 83-100%. 3
• Return to regular activity typically at 6 weeks postoperatively. 3

Alternative Surgical Options

Proximal interphalangeal joint arthroplasty (resection arthroplasty) can be considered but provides less reliable long-term results than arthrodesis. 4, 5, 3

• Allows retained motion but may lead to recurrent deformity over time. 3
• Pain relief and satisfaction rates approach 84-90%. 4
• Consider for patients who specifically desire preserved joint motion. 5

Subtraction osteotomy of proximal phalanx neck preserves joint integrity and may be appropriate in select cases. 6

• Achieves >90% excellent/good results while maintaining proximal interphalangeal joint function. 6
• Restores biomechanical parameters without joint sacrifice. 6

Special Considerations for Diabetic Patients

Risk Stratification

• Diabetic patients with hammer toe and neuropathy are at significantly increased risk for ulceration. 1, 7
• Classify risk using IWGDF criteria (risk 1-3) to determine intensity of preventive interventions. 1

Enhanced Monitoring

• Coach moderate-to-high risk diabetic patients (IWGDF risk 2-3) to self-monitor foot skin temperatures daily. 1
• Temperature difference >2.2°C between corresponding regions on consecutive days requires reduced activity and professional evaluation. 1

Integrated Foot Care

• Provide integrated foot care every 1-3 months for high-risk patients (IWGDF risk 3) and every 3-6 months for moderate-risk patients (IWGDF risk 2). 1
• This must include professional foot care, appropriate footwear, and structured education about self-care. 1

Vascular Assessment

• Obtain immediate vascular assessment including ankle-brachial index and toe pressures before any surgical intervention in diabetic patients. 7
• Critical ischemia (ABI <0.5, ankle pressure <50 mmHg, toe pressure <30 mmHg) requires urgent vascular consultation. 7

Critical Pitfalls to Avoid

• Do not perform nerve decompression procedures for hammer toe prevention in diabetic patients—evidence does not support this intervention. 1
• Avoid excessive osseous resection during arthrodesis, which creates cosmetically undesirable short toes. 3
• Ensure adequate bone resection at the proximal interphalangeal joint to prevent vascular compromise from tension. 3
• Do not use implants that are too large for the toe, particularly in fifth-toe arthrodesis. 3
• For severe deformities, prefer Kirschner wire fixation over permanent implants to allow easy removal if neurovascular compromise occurs. 3