What is the initial management approach for patients referred with hammer toe (hammer toe deformity) from primary care?

Initial Management of Hammer Toe Referrals from Primary Care

Begin with conservative management using appropriate therapeutic footwear and patient education, reserving surgical referral only for cases with pre-ulcerative signs, active ulceration, or failure of conservative treatment after an adequate trial.

Risk Stratification and Assessment

The first critical step is determining whether the patient has diabetes or other high-risk conditions, as this fundamentally changes management priorities:

• Assess for peripheral neuropathy using 10-g monofilament testing or vibration assessment, as loss of protective sensation dramatically increases ulceration risk 1
• Evaluate vascular status by checking pedal pulses and considering ankle-brachial index if pulses are diminished, as peripheral arterial disease affects healing capacity 1
• Inspect for pre-ulcerative signs including erythema, warmth, callus formation, or hemorrhage under callus, which indicate areas of impending tissue breakdown 1
• Document presence of other bony deformities such as prominent metatarsal heads or bunions that compound pressure distribution problems 1

Conservative Management (First-Line for All Patients)

Footwear Modifications

Appropriate therapeutic footwear is the cornerstone of initial management and can prevent progression to ulceration in most cases:

• Extra-wide or depth shoes are needed to accommodate the hammer toe deformity without creating pressure points 1
• Shoes should be 1-2 cm longer than the foot with width equal to the foot at the metatarsophalangeal joints, assessed while standing 1, 2
• Soft uppers and cushioning insoles help redistribute plantar pressure away from deformed areas 2, 3
• Patients should never walk barefoot indoors or outdoors, as this increases injury risk 1, 2

Professional Foot Care

• Regular callus debridement by a trained foot care specialist prevents pressure buildup that leads to ulceration 1
• This should be performed with a scalpel by someone experienced in diabetic foot care, not by the patient 1
• Frequency should be every 3-6 months for monitoring and maintenance, more often if callus reforms quickly 2

Patient Education

Education must be repeated regularly, as single-session education has been shown ineffective:

• Daily foot inspection focusing on areas of redness, particularly between toes and under metatarsal heads 1, 2
• Proper nail care (cutting straight across), daily sock changes with seamless options, and use of emollients for dry skin but not between toes 1, 2
• Patients with neuropathy must substitute visual inspection and hand palpation for lost protective sensation 1

When to Refer for Surgical Evaluation

Surgical referral is indicated in specific high-risk scenarios, not as routine management:

Immediate Referral Criteria

• Pre-ulcerative signs or active ulceration on the distal toe despite conservative treatment 1
• Abundant callus on tip of toe or thickened nails that fail to respond to regular debridement in high-risk diabetic patients 1
• Extreme bony deformities (such as Charcot foot) that cannot be accommodated with commercial therapeutic footwear 1

Surgical Options When Conservative Treatment Fails

The International Working Group on the Diabetic Foot provides specific guidance:

• Digital flexor tenotomy should be considered for high-risk diabetic patients with hammer toes and pre-ulcerative signs or ulcers on the distal toe when conservative treatment fails 1
• This procedure showed 0-20% recurrence rates in case series with 11-36 months follow-up, and no ulcer occurrence in 58 patients with impending ulcers 1
• For non-diabetic patients with rigid deformities, proximal interphalangeal joint arthrodesis provides pain relief in up to 92% with fusion rates of 83-98% 3, 4

Common Pitfalls to Avoid

• Do not delay footwear modification while waiting for specialty referral—this is the most frequent cause of ulceration even in ischemic ulcers 1
• Do not perform aggressive debridement in ischemic or neuro-ischemic feet without signs of infection, as this differs from neuropathic management 1
• Do not assume normal vascular status based on ankle pressures alone in diabetics, as arterial calcification can falsely elevate readings; use toe pressures or TcPO2 if available 1
• Avoid routine surgical referral for asymptomatic hammer toes without high-risk features, as conservative management is highly effective 1, 2, 3

Special Considerations for Diabetic Patients

Integrated foot care programs significantly reduce ulcer recurrence and should be the standard:

• Combine professional foot care, repeated patient education, and appropriate footwear on a regular basis 1
• Home temperature monitoring of foot skin can identify early inflammation before ulceration develops 1
• Medicare data suggests that canceling preventative podiatry coverage increased hospital admissions for diabetic foot ulcers, supporting the value of regular professional care 1