Archive for October, 2012

HAMMER TOE

October 16, 2012

Hammer Toes
Definition:
Hammertoe deformities can cause all types of problems with daily life. This deformity can cause pain and discomfort especially when wearing shoes. These conditions are troubling and are the most the most common deformity of the forefoot.

Anatomy:
A hammertoe is a deformed toe. (See the illustration below) The bone distal to the 1st toe joint is bent toward the floor. Other less common deformities include claw toe which is when both the 1st and 2nd toe joint is bent toward the floor and mallet toe when only 2nd toe joint bent toward the floor, with all other joints normal.
If the bend in the toe does not straighten, regardless if observed in weight bearing or non-weight bearing, position it is know as a rigid deformity. If the deformity is elastic, it will straighten when weight-bearing and return to the hammered (bent) position when the foot is non-weight bearing this is called a flexible deformity.

Figure 1:

The toe to the right of the big toe is a hammertoe.

Note that the 1st Toe Joint, seen here with a circular corn, is bent downward, toward the floor

Symptoms:
Hammertoes can be painful and sometimes there may be no pain or discomfort. When there is pain, it can originate from a variety of areas. The pain and discomfort is usually caused by the patient’s shoe wear. As the deformed toe rubs against the inside of the shoe, this causes pain along the top of the digit. Although people of all ages can develop hammer toes, patients typically do not experience pain or discomfort until early adulthood or later.
Causes:
Hammer toe syndrome can be caused by various factors. The deformity could develop from hereditary factors or as a part of a medical condition such as arthritis. Hammertoes usually occur due to a breakdown or failure in the normal function of the foot. Flat feet, high arch feet, lack of flexibility (especially in the calf), and weakened muscles of the leg and foot can all lead to deformities of the toes. To properly evaluate this condition, it is important to seek a foot and ankle specialist when considering treatment.
Physical Exam:
A complete foot evaluation is needed when evaluating a patient for hammertoe deformities. The foot should be examined in both weight bearing (with the patient standing upright) and non-weight bearing positions to determine if the deformity is flexible. When a deformity is found to be rigid on physical exam, it most likely involves changes in the bone structure. These types of deformities may require more aggressive medical or surgical care.
Diagnostic Studies:
X-rays are used to confirm and assess the deformity. X-rays are best taken with the patient weight bearing and usually include 3 different views. Patients who have been suffering from the deformity for a long period of time may have developed arthritis, and the severity of the arthritis can also be viewed on X-ray. Commonly related deformities of the foot, such as bunions may also be seen when examining an X-ray. These deformities may need to be taken into account when planning the course of treatment.
Non-Surgical Treatment:
The use of padding, taping, footwear changes, and removal of callouses or steroid injections may all be used to help relieve symptoms. Padding can help to reduce abnormal pressures caused by the deformity. Taping techniques or the use of a splint can be used to reduce the a flexible deformity. Changing the patient’s footwear can also help to reduce discomfort. These shoe changes can include a wider or higher toe box to better accommodate the toes. Removal of built-up callouses often associated with hammer toes can help minimize discomfort. Occasionally, steroid injections may be used to temporarily reduce the pain and swelling within the toe joints.
Surgical Treatment:
The goal of hammertoe surgery is to correct the deformity in order to relieve pain and/or restore function to the digit. The degree of surgical intervention will depend on the severity of the deformity. Flexible deformities often require less aggressive surgery. Surgery that decreases the pull of the muscles responsible for the deformity may be used alone or in combination with other procedures at the joint to correct the position of the toes. If the deformity is only partially flexible, or completely rigid, then surgery on the bone structures as well as muscles and joints may be necessary.
Following surgery, full weight bearing with the aid of a specialized shoe/brace is required. However, the time before a patient is able to return to normal footwear and activity will depend on the level of treatment required to correct the deformity.

References:
McGlamry, E., Jimenez, A., Green, G. Lesser ray deformities. In: Banks, A., Downey, M., Martin, D., Miller, S., eds. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Pa: Lippincott Williams and Wilkins; 2001: 253-371
Schuberth, John M. Preferred Practice Guidelines: Hammer Toe Syndrome. Journal of Foot & Ankle Surgery, 38(2), 166-178.
Shirzad, Khalid; Kiesau, Carter D; DeOrio, James K; Parekh, Selene G. Lesser Toe Deformities. J Am Acad Orthop Surg 2011; 19: 505-514.
Thomas, James L et al. Clinical Practice Guidelines: Diagnosis and Treatment of Forefoot Disorders. Section 1: Digital Deformities. Journal of Foot & Ankle Surgery, 48(2), 230-238.