When the toe is permanently bent and every step in a shoe is painful, many people suffer from a hammertoe, medically known as digitus malleus. This common deformity usually affects the second through fourth toes and is often accompanied by other deformities such as hallux valgus or a splayfoot. A hammertoe is not merely a cosmetic issue; the constant bending leads to painful pressure points, corns, and calluses. While conservative treatment is often effective in the early stages to relieve pressure on the toes, surgery is frequently necessary in cases of fixed stiffness. It is important to distinguish between a hammertoe and a claw toe, as treatment varies depending on the type of deformity.
Background Information on Hammertoes
When walking, the feet bear the weight of the entire body. Unsuitable footwear is therefore detrimental to the feet. High heels, stilettos, and similar footwear, in particular, have a negative impact on foot health. More than half of all women wear shoes that are at least half a size to one size too small for the length of their feet.
As a result of wearing ill-fitting shoes, toe deformities—known as hammertoes and claw toes—often occur. Changes in the foot’s skeletal structure (flatfoot with a high arch, hollow foot) can also cause such deformities. In rare cases, other conditions, such as
- neurological disorders,
- chronic polyarthritis, or
- fractures in the lower leg or ankle
be the cause.
What are hammertoes?
In a hammertoe, the toe is bent so far at the distal joint that the toe bone points toward the floor like the head of a hammer. The second toe is usually affected. In severe cases, the misalignment of the joints causes several toes to overlap.
Claw toes should be distinguished from hammer toes. In this deformity, the affected toe is hyperextended at the metatarsophalangeal joint while simultaneously flexed at the middle and distal joints. As a result, the toe curves upward like a claw, and the tip of the toe loses contact with the ground.
A hammertoe is often accompanied by other foot deformities, such as
- flat-valgus foot,
- high arches, or
- hallux valgus (deformity of the big toe).
What are the symptoms of a hammertoe?
In the early stages, hammertoes usually do not cause any discomfort. Often, those affected only see a doctor because they no longer find the appearance of their foot appealing. However, as the deformity progresses, irritation can occur in the affected areas, leading to
- pressure pain,
- calluses, and
- corns, usually above the middle toe joint.
If the friction causes skin lesions, an infection may also develop. This carries risks such as blood poisoning and bone inflammation. In the worst-case scenario, these conditions may necessitate an amputation. Wearing regular shoes is then often no longer possible.
In addition, the deformity can cause other toes to be displaced. This can lead to dislocation of the toes at their proximal joints.
To determine the severity of the toe deformity, an X-ray is performed. This allows the doctor to see
- how far the deformity has progressed,
- which joints are affected, and
- whether toe dislocations are already present.
The X-ray also shows whether any inflammatory changes (arthritis) are associated with the deformity.
How can hammertoes be treated?
In some cases, the doctor may attempt to treat the symptoms using conventional methods—that is, without surgery. For this to be possible, the toes must not yet be completely stiff, and they must still be able to be passively straightened.
The following treatment options are available:
- Addressing the underlying cause,
- physical therapy,
- manual therapy,
- orthopedic shoe inserts,
- Padding and care of pressure points (pressure protection and positioning orthoses),
- strap bandages,
- selection of specially soft leather shoes, shoe fitting, and standard orthopedic shoes, as well as
- custom-made footwear
Over time, the deformity often becomes rigid, and correction using the measures listed above is no longer possible.
In the advanced stages of a hammertoe, chronic inflammation and stiffness develop. These symptoms can have a significant impact on daily life. Patients should then consider surgery performed by a foot surgeon.
The surgeon has several options for treating a hammertoe:
- Straightening the toe,
- Lengthening or repositioning the tendons,
- removal of part of the bone,
- cutting and repositioning the bone, and/or
- fusion of the joint.
The surgical procedure can often be performed on an outpatient basis.
Your doctor can advise you on various surgical methods. The choice depends on
- how severely the toe is bent or stiffened,
- what the underlying causes are and whether there are other deformities or symptoms in the foot, and
- whether the joint can still be moved.
Arthrodesis
This method involves surgically fusing the joint. It can be used for hammertoes with complete stiffness or in cases where multiple toes are affected.
In arthrodesis, the joint (after realignment) is stabilized using a wire, a metal clip, or an implant.
The advantages of this method include reduced pain and a lower risk of swelling. However, the recovery period may be slightly longer.
Hohmann Procedure
In this surgical method, the surgeon shortens the toe bone by removing the proximal phalanx head involved in the joint. The surgeon then lengthens the flexor tendon. This creates a new joint and corrects the toe’s position. For this reason, the method is also called resection arthroplasty.
The toe may need to be immobilized for several weeks with a wire that is visible from the outside. Shortening the bony segment relieves pressure on the soft tissues.
Disadvantages of this method include a higher risk of swelling and the risk of painful irritation within the joint.
On the other hand, the advantages include a shorter recovery period and the relatively simple technical procedure.
Tendon Transposition
In cases of hammertoes that are still mobile and do not have significant additional deformities, tendon transfer is an option.
The procedure is performed solely on the soft tissues, not on the bone. If the surgery is successful, the individual toes can be repositioned. This reverses the flexion of the toes into extension, thereby correcting the deformity without causing stiffness.
Shortening of the Metatarsal Bones (e.g., Weil Osteotomy)
In these traditional procedures, such as the Weil osteotomy, a metatarsal bone is shortened. This may be necessary to better balance the load on the forefoot among the various bones. This also allows a dislocated metatarsal to be repositioned.
A biomechanical analysis may also be useful prior to such a surgery. This allows the surgeon to determine whether there is potential stress on a specific region.
Minimally Invasive Surgery
In recent years, minimally invasive procedures have also become established for treating hammertoe. In these procedures, the surgeon makes only small incisions and uses specialized techniques. This allows the surgeon to avoid a more extensive operation and often makes postoperative care easier for the patient.
Your foot surgeon will explain whether this type of surgery is an option for you.
FAQ: The 8 Most Important Questions About Hammer Toes and Claw Toes
What is the difference between a hammertoe and a claw toe?
The distinction between a hammertoe and a claw toe lies in the specific position of the joints. In a hammertoe, the distal joint of the toe is maximally flexed, so that the tip strikes the ground like a hammer; often, the middle joint is also affected. In a claw toe, on the other hand, the metatarsophalangeal joint in the foot is hyperextended, while the middle and distal joints are flexed, resembling an animal’s claw. Since the distinctions can be subtle and hammer toes and claw toes often occur simultaneously on the same foot, the terms are frequently used interchangeably in everyday language to describe these toe deformities.
How do hammer toes develop?
The development of a hammertoe is usually a gradual process spanning many years. The most common cause is wearing shoes that are too tight in the front or have high heels. These shoes force the toes into a flexed position. If this is compounded by an imbalance in the foot muscles—such as from a splayfoot or hallux valgus—the tendons shorten and the joint capsule shrinks. Neurological disorders or rheumatism can also lead to hammertoes. Some people with hammertoes also have a genetic predisposition that increases the likelihood of developing them.
What symptoms does a hammertoe cause?
The symptoms of a hammertoe often begin with slight redness at the toe joints. Constant friction inside the shoe leads to painful pressure points, corns (clavus), and inflamed bursa. The second through fourth toes are particularly often affected. If the affected toe remains permanently bent, the joint becomes increasingly stiff. Patients report pain when walking and difficulty finding shoes that fit, as the curved toe requires more space inside the shoe.
Can hammertoes be treated conservatively?
Yes, as long as the hammertoe is flexible—meaning it can still be passively straightened by hand—conservative treatment is both possible and advisable. This includes wearing comfortable shoes with soft uppers and sufficient space for the toes, as well as using insoles that support the transverse arch. Tension bandages, night splints, and silicone orthoses can help gently correct the deformity. Physical therapy and targeted toe exercises also strengthen the foot muscles and can slow the progression of the condition.
When is surgery necessary?
Surgery is recommended in orthopedics when conservative measures no longer alleviate the symptoms, the deformity has become fixed (contracted), or open wounds and severe calluses have formed. The goal of surgical correction is to permanently straighten the toe. Common procedures include the Hohmann procedure, in which part of the bone is removed (resection arthroplasty), or fusion (arthrodesis) of the affected joint. In modern clinics, minimally invasive techniques that preserve tissue are increasingly being used.
What shoes should you wear if you have hammertoes?
The right footwear is crucial for relieving pressure. You should wear soft, wide shoes that have no seams in the forefoot area to avoid pressure points. Shoes with sufficient space in the toe box prevent the toes from being compressed. High-heeled shoes and tight toe boxes should be avoided, as they contribute to hammertoes. In severe cases, custom-made orthopedic shoes may be necessary to provide pain-free support for the foot.
How are hammertoes diagnosed?
The doctor usually makes the diagnosis simply by looking at the foot (visual diagnosis). He or she checks whether the deformity is still flexible or whether the joints have already stiffened. An X-ray shows the extent of the bony changes and whether the joint surfaces are still intact. This is important for determining whether the condition is a hammertoe or a claw toe and which treatment—conservative or surgical—offers the best chance of success.
Can hammertoes be prevented?
To prevent hammertoes from developing, wearing properly fitting shoes is essential. You should walk barefoot as often as possible to strengthen the foot muscles. Regular foot exercises, such as picking up objects with your toes, help keep the tendons and joints flexible. Anyone who notices the first signs of a deformity should see an orthopedist early on to use insoles or padding to prevent the condition from progressing and stop hammertoes from developing in the first place.
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