What are the treatment options for an adult patient with hammer toe?

Hammer Toe Treatment

For flexible hammer toe deformities, start with conservative management including proper footwear with wide toe-box, toe orthoses, and professional callus removal; for rigid deformities or when conservative treatment fails, proceed to surgical correction with proximal interphalangeal joint arthrodesis or digital flexor tenotomy depending on the specific clinical presentation. 1, 2

Conservative Treatment (First-Line for Flexible Deformities)

Footwear Modifications

• Prescribe extra-depth shoes with wide toe-box and soft uppers to accommodate the deformity and reduce pressure on bony prominences 2, 1
• Consider custom-made insoles or toe orthoses (silicone or semi-rigid devices) for patients with foot deformity or pre-ulcerative signs 2
• Padding of osseous prominences can provide symptomatic relief 1

Professional Foot Care

• Provide regular professional treatment for excess callus, nail changes, and pre-ulcerative lesions on the toe apex or distal part 2, 3
• Integrated foot care should be repeated every 1-3 months for high-risk patients (particularly diabetics) 2, 3

Adjunctive Conservative Options

• Kinesiology taping may provide symptomatic relief for flexible deformities by correcting toe position, though this represents a temporary solution 4
• Stretching exercises and metatarsal pads can be considered for flexible deformities 1

Surgical Treatment Indications

When to Operate

• Rigid deformities that do not passively correct without causing pain require surgical intervention 1
• When conservative treatment fails in patients with hammertoes and pre-ulcerative signs or distal toe ulcers 2
• Persistent pain despite adequate conservative management 1, 5

Surgical Options by Clinical Scenario

For Flexible Deformities with Pre-ulcerative Signs (Diabetic Patients)

• Digital flexor tenotomy is now recommended as first-line surgical treatment for neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity 2
• This procedure achieves 92-100% ulcer healing in mean 21-40 days with low complication rates 2
• Can be performed in outpatient setting without subsequent immobilization 2
• Recurrence rates of 0-20% over 11-36 months follow-up 3

For Rigid Deformities

• Proximal interphalangeal joint arthrodesis is the definitive treatment for fixed-flexion deformities 1, 6
• Provides pain relief in up to 92% of patients with osseous fusion rates of 83-98% 1
• Patient satisfaction rates range from 83-100% 1

Surgical technique for arthrodesis includes:

• Longitudinal incision over the proximal interphalangeal joint 1
• Transverse extensor tenotomy and capsulotomy 1
• Resection of articular surfaces of proximal and middle phalanges 1
• Fixation with Kirschner wire, screws, or intramedullary implants 1, 6

Alternative: Proximal Phalanx Osteotomy

• Subtraction osteotomy of the proximal phalanx neck preserves joint integrity while correcting deformity 7
• Achieves >90% excellent/good results with restoration of biomechanical parameters 7
• Consider in younger, active patients where joint preservation is valued 7

Addressing Metatarsophalangeal Joint Involvement

• If dorsal contracture of the metatarsophalangeal joint is present (elevating the toe), perform Z-lengthening of long extensor tendon and capsulectomy 1
• Release collateral ligaments from metatarsal neck if angular deformity persists 1
• Consider metatarsal osteotomy if residual subluxation remains after soft-tissue procedures 1

Special Considerations for Diabetic Patients

Risk Stratification

• Diabetic patients with hammertoes and pre-ulcerative signs (callus, nail changes) require immediate professional treatment to prevent ulceration 3, 8
• Even without visible swelling or discoloration, ongoing mechanical trauma creates pre-ulcerative conditions 8

Surgical Approach in Diabetics

• Digital flexor tenotomy combined with ankle-high offloading devices shows moderate evidence for healing with 0% ulcer occurrence in 58 patients over 11-31 months 3, 2
• Post-operative infection risk is 9.5% in diabetic neuropathy patients, requiring careful patient selection 3

Common Pitfalls to Avoid

• Avoid excessive osseous resection during arthrodesis, which leads to cosmetically undesirable short toe 1
• Ensure adequate bone resection at proximal interphalangeal joint to prevent vascular compromise 1
• Most implants are too large for fifth-toe arthrodesis; use Kirschner wire for severe deformities to allow easy removal if neurovascular compromise occurs 1
• Longitudinal incisions can lead to scar contracture elevating the toe; consider elliptical incisions for better cosmesis 1

Postoperative Management

• Return to regular activity typically at 6 weeks postoperatively 1
• Wide shoes and activity modifications continued for several additional weeks 1
• Persistent pain or swelling may occur; some patients benefit from formal physical therapy 1
• Teach proper nail trimming technique (straight across, not curved) and daily foot inspection for diabetic patients 8