Hammertoe: Causes, Treatment & Surgery | DPM

Hammertoe is the most common lesser toe deformity we treat at Balance Foot & Ankle — and one of the most successfully corrected when addressed at the right time. If you’ve noticed one or more of your smaller toes bending downward at the middle joint, you’re dealing with a hammertoe deformity. Here’s what’s happening and what we can do about it.

What Is a Hammertoe?

A hammertoe is a contracture deformity at the proximal interphalangeal (PIP) joint — the first joint distal to the foot — causing the toe to curl downward at that joint while the distal toe tip may press against the ground. The second toe is most commonly affected, though any lesser toe can develop the deformity.

The deformity results from an imbalance between the long flexor and extensor tendons of the toe and the intrinsic (small) muscles within the foot. When this balance is disrupted — by footwear, structural foot mechanics, or neurological changes — the long flexor tendon overpowers the dorsal extensor mechanism, pulling the PIP joint into flexion.

Hammertoe differs from two related conditions: mallet toe (contracture at the distal IP joint — the tip of the toe bends down) and claw toe (contracture at both the PIP and DIP joints with MTP joint extension — more severe, often systemic cause).

Causes and Risk Factors

• Ill-fitting footwear — shoes with a narrow toe box force the toes into flexed positions for prolonged periods. High heels further load the forefoot and compress the toes. Over years, the soft tissues adapt to this chronic position.
• Bunion deformity — a bunion pushes the big toe toward the second toe, which frequently buckles under this chronic lateral pressure into a hammertoe position.
• Long second toe (Morton’s toe) — a second toe that’s longer than the first has less room in most shoe toe boxes and is more prone to hammertoe development.
• Flat feet (pes planus) — overpronation destabilizes the forefoot and disrupts the intrinsic muscle balance that keeps the lesser toes straight.
• Neuropathy — peripheral neuropathy (especially from diabetes) causes intrinsic muscle atrophy and wasting, which eliminates the counterbalance to the long flexor tendons. Claw toe deformity (more severe) is particularly associated with neuropathy.

Flexible vs. Rigid Hammertoe

The most clinically important distinction is whether the hammertoe is flexible or rigid:

• Flexible hammertoe — the toe can be manually straightened (placed flat on the floor or straightened by gentle hand pressure). The joint has not yet become fixed. Conservative treatment is effective; surgical correction is simple when needed.
• Rigid hammertoe — the toe is contracted and cannot be straightened passively. The joint capsule and surrounding ligaments have contracted permanently. Conservative care relieves symptoms but cannot correct the deformity; surgery is needed for structural correction.

Conservative Treatment

• Footwear — shoes with a wide, deep toe box that accommodate the bent toe without rubbing. The toe box should be at least as tall as the highest point of the hammertoe.
• Toe splints/strapping — silicone or foam splints hold the toe in a straighter position and cushion the dorsal prominence from shoe friction. Toe loops and buddy-taping to the adjacent toe can also help.
• Padding and cushioning — metatarsal pads behind the ball of the foot redistribute pressure and reduce the driving force on the toe. Corn pads on the toe knuckle protect against shoe friction.
• Custom orthotics — for hammertoes driven by flat feet or excessive pronation, orthotics address the mechanical root cause. Metatarsal pads can be incorporated.
• Debridement — corns and calluses on the dorsal PIP prominence can be professionally debrided at our office to relieve direct pain.

Hammertoe Surgery

When conservative care fails or the deformity is rigid, surgical correction provides definitive realignment. The choice of procedure depends on whether the hammertoe is flexible or rigid:

• Flexor tendon transfer (flexible hammertoe) — the long flexor tendon (which is driving the deformity) is rerouted to the top of the toe to act as an extensor, correcting the imbalance. Excellent results with minimal recovery. No bone is removed.
• PIP joint arthroplasty (proximal interphalangeal resection) — a small portion of the proximal end of the middle phalanx is removed, allowing the joint to straighten. A temporary pin is placed for 4–6 weeks. The most common hammertoe procedure for rigid deformity.
• PIP joint arthrodesis (fusion) — the joint is fused in a straight position for a more permanent correction. Preferred when there’s significant instability or the arthroplasty has failed.

Recovery from hammertoe surgery is generally quick — most patients walk in a surgical shoe immediately, return to regular shoes in 4–6 weeks, and are fully recovered in 2–3 months. It is frequently performed as an outpatient procedure combined with other forefoot surgery (bunionectomy, metatarsal osteotomy) on the same visit.

Frequently Asked Questions

Can hammertoe correct itself without surgery?

Flexible hammertoes can be managed and stabilized conservatively with proper footwear and splinting. However, hammertoes are progressive — without addressing the driving forces, most flexible hammertoes eventually become rigid. Conservative treatment is not a cure; it’s management. Early surgical correction of a flexible hammertoe (a simple tendon transfer) is a minor 20-minute procedure with minimal recovery and prevents the more complex surgical correction needed once the toe becomes rigid.

How long is hammertoe surgery recovery?

Most patients walk in a surgical shoe within 24 hours. Return to regular shoes typically occurs at 4–6 weeks. Complete swelling resolution and full activity return occurs at 2–3 months. The toe may remain slightly swollen for up to 6 months — this is normal and not a sign of a problem. Patients who have hammertoe correction combined with bunion surgery have the same general recovery timeline.

Sources

1. Myerson MS, Shereff MJ. “The pathological anatomy of claw and hammer toes.” Journal of Bone and Joint Surgery. 1989;71(1):45-49.
2. Coughlin MJ. “Operative repair of the mallet toe deformity.” Foot & Ankle International. 1995;16(3):109-116.