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.

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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.

More questions patients ask

What exactly is a hammertoe deformity?

A hammertoe is a flexion deformity at the proximal interphalangeal (PIP) joint of a toe — the middle joint bends downward (plantarflexes) while the metatarsophalangeal (MTP) joint is simultaneously extended (dorsiflexed), creating a characteristic 'hammer' shape. It is distinguished from mallet toe (flexion only at the distal interphalangeal joint) and claw toe (flexion at both PIP and DIP joints with MTP extension). The deformity most commonly affects the 2nd through 5th toes. It begins as a dynamic, flexible deformity driven by muscular imbalance — in this stage the toe can be manually straightened. Over months to years, the joint capsule and surrounding ligaments adaptively shorten in the flexed position, creating a rigid, fixed contracture that cannot be passively corrected.

What is the difference between a flexible and rigid hammertoe?

The flexible-to-rigid distinction is the most clinically important classification for hammertoe because it determines whether conservative treatment is effective. A flexible hammertoe: the toe can be manually straightened to its anatomically correct position; the deformity is caused by a dynamic muscular imbalance (overactive flexors, underactive intrinsics) without permanent joint contracture; orthotics, splinting, and footwear changes can prevent progression and reduce symptoms. A rigid hammertoe: the PIP joint cannot be passively extended — the capsule, plantar plate, and collateral ligaments have permanently shortened in the flexed position; conservative care does not correct the deformity (only manages symptoms); surgical correction is the only option for permanent relief, typically involving PIP joint arthroplasty (resection of the proximal phalanx head) or arthrodesis (fusion of the PIP joint). Patients often transition from flexible to rigid over 2–5 years of untreated deformity.

What non-surgical treatments help hammertoes?

Non-surgical hammertoe management is appropriate for flexible deformities and for symptom management in rigid deformities where surgery is not yet indicated. Footwear is the most impactful intervention: a shoe with a wide, rounded toe box and adequate depth accommodates the hammertoe without creating dorsal corn pressure. Hammertoe splints hold the PIP joint in extension during the day or night, preventing further contracture in flexible deformities. Silicone corn pads or tube foam protect the dorsal bony prominence from shoe pressure. Toe exercises (towel scrunching, toe splay, marble pickup) maintain intrinsic muscle activity in flexible deformities. Metatarsal pads address the MTP joint hyperextension component of claw toe deformity. Custom orthotics targeting the underlying biomechanical cause (overpronation, bunion mechanics) slow or halt progression.

What does hammertoe surgery involve?

Hammertoe surgery is typically performed as an outpatient procedure under local anesthesia (digital block) combined with intravenous sedation if desired. For flexible hammertoes: flexor-to-extensor tendon transfer (Young's procedure) — the long flexor tendon is transferred dorsally to function as an extensor, correcting the dynamic imbalance; this preserves the PIP joint and is appropriate only for fully flexible deformities. For rigid hammertoes: PIP joint arthroplasty — the head of the proximal phalanx is resected, a small intramedullary pin or implant is placed temporarily to maintain alignment during healing, and the shortened joint heals in a straighter position; recovery involves 4–6 weeks in a surgical shoe, with the pin removed at 3–4 weeks in pinning cases. The overall surgical result: 85–90% patient satisfaction; persistent mild swelling for 3–6 months is common; the toe appears shorter and straighter than before.

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