What is the recommended initial management for a painful hammer toe with callus formation and difficulty wearing shoes?

Initial Management of Painful Hammer Toe with Callus Formation

Begin with conservative management including professional callus debridement, appropriate footwear modifications, and orthotic interventions before considering surgical options. 1

Immediate Conservative Treatment

Professional Callus Management

• Have calluses debrided by a trained foot care specialist or healthcare provider with experience in foot care using a scalpel—patients should never attempt self-removal with chemical agents or plasters 1
• Regular professional foot care should be provided to treat pre-ulcerative lesions and excess callus to prevent foot ulceration 1

Footwear Modifications

• Prescribe extra-depth shoes or depth shoes to accommodate the hammer toe deformity and reduce pressure on the affected digit 1
• The shoe should be 1-2 cm longer than the foot, with internal width equal to the foot width at the metatarsophalangeal joints, and sufficient height to accommodate the toes 1
• Consider custom-made footwear or custom-made insoles if the deformity significantly increases pressure 1

Orthotic Interventions for Non-Rigid Hammer Toes

• For non-rigid hammer toes with callus formation, prescribe toe silicone or semi-rigid orthotic devices to reduce excess callus 1
• These devices help redistribute pressure away from the apex or distal part of the affected toe 1

Patient Education and Self-Care

• Instruct patients on daily foot inspection, particularly if they have diabetes or neuropathy 1
• Educate on proper footwear selection that accommodates foot shape and fits properly 1
• Advise against walking barefoot indoors or outdoors, and emphasize wearing shoes with socks 1
• Teach patients to use lubricating oils or creams for dry skin (but not between toes) 1

When Conservative Management Fails

Surgical Consideration for Non-Rigid Deformities

• Consider digital flexor tendon tenotomy for non-rigid hammer toes with persistent nail changes, excess callus, or pre-ulcerative lesions despite conservative treatment 1
• This procedure can help prevent first or recurrent foot ulcers in at-risk patients 1

Surgical Options for Rigid Deformities

• For rigid hammer toe deformities that fail conservative treatment, proximal interphalangeal joint resection arthroplasty or arthrodesis are effective options 2, 3
• Arthrodesis provides more reliable fixation with pain relief in up to 92% of patients and patient satisfaction rates of 83-100% 3
• Fusion rates range from 83-98% with this approach 3

Special Considerations for High-Risk Patients

Diabetic Patients

• Refer diabetic patients with hammer toe deformities to a podiatrist for evaluation, as these deformities place them at moderate to high risk for foot ulcer development 1
• Provide integrated foot care including professional foot care, adequate footwear, and structured education 1
• Monitor high-risk diabetic patients every 1-3 months, and moderate-risk patients every 3-6 months 1

Patients with Peripheral Neuropathy

• These patients require more frequent monitoring as they have loss of protective sensation 1
• Educate them to substitute visual inspection and hand palpation for sensory surveillance 1

Common Pitfalls to Avoid

• Never allow patients to self-treat calluses with chemical agents, plasters, or sharp instruments—this significantly increases ulceration risk 1
• Avoid shoes that are too tight or too loose; always fit footwear with the patient standing, preferably at the end of the day when feet are most swollen 1
• Do not dismiss hammer toes as merely cosmetic—they substantially increase ulceration risk in neuropathic patients and fall risk in elderly patients 1
• Ensure adequate bone resection during surgical correction to avoid vascular compromise, but avoid excessive resection that creates a cosmetically undesirable short toe 3