What is the treatment for hammertoes or deformities of the 4th and 5th toes?

Treatment of 4th and 5th Toe Hammertoe Deformities

For flexible hammertoe deformities of the 4th and 5th toes, begin with conservative management including proper footwear with adequate toe box depth, custom orthoses, and padding; if conservative treatment fails and ulceration develops, proceed directly to digital flexor tenotomy as first-line surgical intervention. 1

Initial Conservative Management

Start with non-surgical approaches for all flexible deformities:

• Footwear modification: Select shoes that are firm, comfortably fitting, with appropriate length and width, rounded toe box, and flexible flat sole with heel support 2
• Extra-depth shoes to accommodate the toe prominence without causing pressure 3
• Custom pressure-relieving orthoses for patients with increased plantar pressures 3
• Padding of osseous prominences to reduce friction and prevent skin breakdown 4
• Kinesiology taping may provide symptomatic relief for flexible deformities, though evidence is limited 5

Key assessment point: Determine if the deformity is flexible (correctable without pain) or rigid (fixed contracture). This distinction drives all subsequent treatment decisions. 4

When Conservative Treatment Fails

For flexible hammertoes with ulceration or pre-ulcerative signs:

• Digital flexor tenotomy is now the first-line surgical treatment for neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity 1
• This represents a significant shift from previous practice—tenotomy is no longer reserved for recalcitrant cases but should be used early when ulcers develop 1
• The procedure achieves 97% healing rate in mean 29.5 days 1
• Can be performed in outpatient clinic with minimal resources 1
• Combine with removable ankle-high offloading devices for optimal outcomes 1

For rigid hammertoe deformities:

• Proximal interphalangeal (PIP) joint arthrodesis is the definitive treatment for rigid deformities that fail conservative management 6, 4
• Achieves osseous fusion rates of 83-98% and patient satisfaction rates of 83-100% 4
• Pain relief occurs in up to 92% of patients 4
• Provides more reliable fixation than arthroplasty, which may lead to recurrent deformity over time 4

Surgical Technique Considerations

For digital flexor tenotomy:

• Limited to digits 2-5 (not first toe, which has different pathophysiology) 1
• Indicated specifically for flexible deformities with plantar or apex ulcers 1
• Small risk of transfer lesions but zero amputations in controlled trials 1

For PIP joint arthrodesis:

• Resect articular surfaces of proximal and middle phalanges to allow osseous apposition 4
• Address dorsal contracture of metatarsophalangeal joint with Z-lengthening of extensor tendon if present 4
• Fixation options include smooth Kirschner wire (traditional), screws, bioabsorbable pins, or intramedullary implants 6, 4
• Internal fixation devices avoid exposed hardware and eliminate need for secondary pin removal 4

Special Population: Diabetic Patients

Diabetic patients with 4th/5th toe deformities require heightened vigilance:

• Risk stratification is essential—patients with loss of protective sensation or peripheral arterial disease need more frequent monitoring 3
• Regular foot inspection daily, with particular attention to areas of pressure from the deformity 1, 3
• Never walk barefoot indoors or outdoors 1
• Avoid self-care of calluses that develop secondary to the deformity 3
• Refer to foot care specialists for moderate to high-risk patients 3
• If ulceration develops with infection or ischemia, address the infection/ischemia first before definitive offloading 1

Common Pitfalls and Caveats

Critical errors to avoid:

• Do not delay tenotomy in diabetic patients with flexible hammertoes and ulceration—this is now first-line treatment, not a last resort 1
• Avoid excessive bone resection during arthrodesis, which creates cosmetically undesirable short toes 4
• Ensure adequate bone resection at PIP joint to prevent vascular compromise 4
• Most implants are too large for 5th toe arthrodesis—use Kirschner wire for severe 5th toe deformities 4
• Failure to address footwear undermines all other interventions—this is the most common cause of treatment failure 2
• Longitudinal incisions across PIP joint provide better exposure but can cause scar contracture that elevates the toe; consider elliptical incisions 4

Monitoring and Follow-up

• Schedule regular follow-up every 3-6 months based on symptom severity 2
• Monitor for changes in pain levels, mobility, and development of new deformities 2
• Patients typically return to regular activity at 6 weeks post-operatively after surgical intervention 4
• Wide shoes and activity modifications continue for several additional weeks 4