Hammertoe Causes 2026: Why Toes Bend | Podiatrist DPM

Table of Contents

1. What Is a Hammertoe
2. What Causes Hammertoe
3. Risk Factors for Developing Hammertoe
4. Flexible vs Rigid Hammertoe
5. Symptoms and How Hammertoe Progresses
6. How a Podiatrist Diagnoses Hammertoe
7. Non-Surgical Treatment
8. Products That Help
9. When Surgery Is Needed
10. Red Flags: See a Podiatrist
11. Most Common Hammertoe Mistake
12. Frequently Asked Questions
13. Sources

One of the most common questions patients bring to our clinic is a simple one: “Why does my toe bend like this?” They’ve noticed the second toe (or third, or fourth) curling downward at the middle knuckle, forming a distinctive arch shape. A corn has started developing on top of the bent joint from shoe pressure. The toe won’t straighten when they try to push it down. Understanding what caused the hammertoe is essential — not just for treating the existing deformity, but for preventing the other toes from developing the same problem over the coming years.

What Is a Hammertoe

A hammertoe is a deformity of the lesser toes (2nd through 5th) in which the proximal interphalangeal (PIP) joint — the middle knuckle of the toe — is contracted in a downward, flexed position. In a normal toe, the extensor tendons (running along the top) and flexor tendons (running along the bottom) are balanced, maintaining the toe in a relatively flat, straight alignment. When this balance is disrupted — by any of the several causes detailed below — the flexor tendons gain a mechanical advantage and pull the PIP joint into persistent flexion. Over months to years, if the imbalance is not corrected, the joint progressively stiffens until the deformity becomes rigid and fixed.

Hammertoe is anatomically distinct from claw toe (which involves both the PIP and DIP joints bending downward with the metatarsophalangeal joint hyperextending) and mallet toe (which involves only the DIP joint — the outermost knuckle). The practical distinction matters because treatment differs by joint: hammertoe is a PIP problem, and surgical correction targets the PIP joint specifically. In our clinic, we see hammertoe most commonly in the second toe, which is also anatomically the longest toe in many patients — placing it at highest risk of the footwear-related causes described below.

What Causes Hammertoe

Hammertoe results from a muscular imbalance — specifically, a relative overpowering of the flexor digitorum longus (the tendon that bends the toe downward) compared to the intrinsic foot muscles (the lumbricals and interossei) that normally extend the PIP joint and keep the toe flat. This imbalance can originate from multiple sources, often acting in combination:

1. Improper Footwear — The Primary Mechanical Cause

Shoes with toe boxes too short for the foot’s digit length force the toes to assume a bent position to fit within the shoe. Over years of daily wearing, the intrinsic foot muscles adapt to this shortened position — they atrophy from disuse while the flexor tendons remain strong, creating the muscular imbalance that defines hammertoe. High-heeled shoes compound this by pitching the foot forward and compressing all digits against the front of the shoe while the heel sits elevated. Studies in the podiatric literature consistently identify narrow or short footwear as the predominant environmental cause of lesser toe deformities in the adult population. The fact that hammertoe is significantly more common in women — who wear fashion shoes with narrower toe boxes and higher heels at higher rates — supports this etiology.

2. Bunion (Hallux Valgus) — The Biomechanical Displacement Cause

A bunion at the big toe (hallux) pushes the first metatarsal medially and the big toe laterally — directly toward the second toe. As the bunion enlarges, the great toe increasingly crowds the second toe, pushing it upward and forcing the PIP joint into flexion. This is so consistent that most patients with moderate-to-advanced bunions develop a second-toe hammertoe as a consequence. In our surgical planning, we commonly address both deformities simultaneously — correcting the bunion without addressing the hammertoe leaves the second toe susceptible to recurrence from the same mechanical forces.

3. Flat Foot (Pes Planus) — The Intrinsic Muscle Overload Cause

In a flat foot, the arch collapses during weight-bearing, causing the toes to “grip” the ground to help stabilize the foot — a compensation pattern called toe flexor recruitment. This chronic over-activation of the flexor tendons, coupled with stretch-weakening of the intrinsic muscles from the pronated position, creates the same muscular imbalance that causes hammertoe. Patients with severe flat feet who walk barefoot on hard floors are at particular risk, as the grip response is most pronounced without footwear to provide arch support.

4. Long Second Toe (Morton’s Toe) — The Anatomical Length Cause

When the second toe is longer than the first (a common anatomical variant called Morton’s foot or Greek foot, present in approximately 20% of the population), it receives disproportionate pressure from the front of the shoe. A standard shoe is designed to accommodate a first toe that is longest — when the second toe is longer, it bears the impact of the toe box constantly, forcing it into a flexed position every time the shoe compresses. Over years, this positional stress drives PIP joint contracture. Correctly sized footwear (with the box sized to the longest toe, not just foot length) is essential for these patients.

5. Neuromuscular Conditions — The Neurological Cause

Any condition that weakens the intrinsic foot muscles disrupts the extension force on the PIP joint, allowing the flexor to dominate and produce hammertoe deformity. Peripheral neuropathy from diabetes is the most common neurological cause — loss of intrinsic muscle innervation creates the “intrinsic minus” foot characterized by claw toes and hammertoes. Charcot-Marie-Tooth disease (hereditary motor and sensory neuropathy) produces severe claw toe and hammertoe deformity as a primary feature due to length-dependent axonal loss affecting intrinsic muscles before extrinsic ones. Stroke-related foot drop and cerebral palsy also produce hammer and claw toe deformities through spastic imbalance between flexors and extensors.

6. Prior Injury or Surgery — The Traumatic Cause

Fractures of the toe or metatarsal that heal in malalignment, plantar plate tears at the metatarsophalangeal joint (which destabilize the MTP joint and allow the toe to drift into flexion), and prior failed toe surgery can all lead to acquired hammertoe deformity. Second MTP plantar plate tears in particular are frequently underdiagnosed — they present as a painful, dorsally displaced second toe that looks like a hammertoe but is actually caused by the torn stabilizing ligament at the ball of the foot.

Risk Factors for Developing Hammertoe

Risk Factor	Mechanism	Relative Risk
Female sex	Higher rates of narrow/high-heeled shoe use	Very high
Age over 50	Progressive intrinsic muscle atrophy and loss of toe flexibility	High
Bunion (hallux valgus)	2nd toe crowding and lateral displacement	Very high
Flat foot (overpronation)	Chronic flexor over-recruitment and intrinsic stretch weakness	High
Long 2nd toe (Morton’s foot)	Chronic shoe box impingement on longest toe	High
Diabetes with neuropathy	Intrinsic muscle denervation producing intrinsic minus foot	Very high
Family history of hammertoe	Inherited foot structure predisposing to deformity	Moderate
Prior 2nd MTP plantar plate tear	Destabilization of MTP joint allowing dorsal displacement	High

Flexible vs Rigid Hammertoe

The most clinically important distinction in hammertoe evaluation is whether the deformity is flexible or rigid. This single determination guides the entire treatment plan. A flexible hammertoe can be passively straightened — you or your podiatrist can manually straighten the toe to a normal position. The intrinsic-extrinsic muscular imbalance is present, but the joint itself has not yet developed fixed contracture. Flexible hammertoes respond well to conservative treatment and have excellent outcomes with surgical correction when needed. A rigid hammertoe cannot be manually straightened — the PIP joint capsule has contracted, articular cartilage changes are present, and the tendon has adaptively shortened. Rigid deformities require surgical correction and cannot be “stretched” into alignment.

In our clinic, we assess flexibility at every hammertoe visit because flexible deformities progress to rigid over time — the window for conservative success closes as stiffness develops. Patients who present early (when the toe can still be straightened) have far more treatment options and better long-term outcomes than those who present after years of progressive rigidity.

Symptoms and How Hammertoe Progresses

Early hammertoe (flexible stage) may be asymptomatic — the toe looks bent but causes no pain. As the deformity progresses, the dorsal (top) aspect of the PIP joint begins to rub against the shoe upper, causing a corn (heloma durum) to form. This corn is the most common source of pain in established hammertoe. The corn’s central translucent core creates a pressure point that feels like walking on a pebble with every step. In advanced cases, the MTP joint also deforms — the toe lifts at the ball of the foot, causing pain at the metatarsal head below and the corn above simultaneously. In the most severe cases, the toe crosses over or under adjacent toes, skin breakdown occurs over the corn, and walking becomes significantly limited.

How a Podiatrist Diagnoses Hammertoe

Diagnosis is clinical, confirmed with weight-bearing X-rays. Physical examination documents: which joints are involved (PIP only = hammertoe, PIP + DIP + MTP = claw toe, DIP only = mallet toe), whether the deformity is flexible or rigid, the presence and grade of any associated corn, MTP joint stability (drawer test for plantar plate integrity), and associated deformities (bunion, flat foot, digit length pattern). Weight-bearing X-rays reveal the degree of bony deformity, articular joint space, and any periarticular bone changes. MRI or ultrasound is added when plantar plate tear is suspected as the underlying driver of the hammertoe.

Non-Surgical Treatment for Hammertoe

Conservative treatment is effective for flexible hammertoes and focuses on three goals: eliminating the pain source (corn care), reducing the mechanical pressure that drives the deformity (footwear and padding), and addressing the underlying muscular imbalance (stretching and toe exercises). Conservative care cannot reverse a rigid deformity — it can only slow progression and manage pain.

• Footwear modification: Shoes with a deep, wide toe box (at least as wide as the widest part of the foot and long enough that the longest toe has a thumb’s width of space). Stretchable toe box fabrics accommodate the raised PIP joint. Avoid narrow, pointed, or heeled shoes entirely during treatment.
• Toe padding: Felt or foam donut pads placed around the corn reduce pressure from the shoe upper. Gel corn pads provide cushioning. Silicone toe sleeves over the PIP joint are convenient for daily use.
• Professional corn debridement: Regular trimming of the corn by a podiatrist reduces pain acutely. Never attempt to cut a corn yourself — blade injury risk is significant, especially in diabetic patients.
• Toe stretching and splinting: Manually stretching the PIP joint into extension for 2–3 minutes, twice daily, can slow progression in flexible deformities. Toe straightening splints worn at night passively maintain extension position, preventing overnight contracture.
• Intrinsic strengthening exercises: Towel curls, marble pickups, and short-foot exercises (attempting to shorten the foot by pulling toes toward heel) strengthen the intrinsic muscles that normally balance the flexor tendons.

Products That Help Hammertoe

When Surgery Is Needed for Hammertoe

Surgery is indicated when: the hammertoe is rigid and cannot be straightened, conservative care fails to control pain adequately, skin breakdown or ulceration occurs over the corn, the deformity interferes significantly with footwear fitting and daily activities, or the toe crosses over adjacent toes causing additional problems. For flexible hammertoes, the tendon transfer procedure (flexor-to-extensor tendon transfer) redirects the flexor tendon from the bottom of the toe to the top, converting a deforming force to a corrective one. For rigid hammertoes, PIP arthroplasty (removal of a small segment of bone at the PIP joint to shorten and straighten the toe) or PIP arthrodesis (fusing the PIP joint in a straight position) is performed. Recovery from hammertoe surgery is typically 4–6 weeks in a post-operative shoe, followed by transition to wide athletic shoes.

Most Common Hammertoe Mistake

The most common mistake we see is cutting the corn at home. Patients with a painful corn over a hammertoe PIP joint frequently attempt to remove it with a razor, nail scissors, or corn-removing liquid acid. The result is either an incomplete removal that quickly regrows, or a laceration that becomes infected — particularly dangerous in diabetic or immunosuppressed patients. Corns are symptoms of the underlying deformity — removing the corn without addressing the mechanical cause means the corn will regrow within weeks. The second most common mistake is delaying treatment until the deformity is rigid. Flexible hammertoes have excellent non-surgical and surgical outcomes. By the time a hammertoe is fully rigid, joint changes are present and surgical correction is more complex, with a longer recovery. Early evaluation — when you first notice the toe bending — is always better.

Frequently Asked Questions

Can hammertoe be reversed without surgery?

Flexible hammertoes (those that can be manually straightened) can be managed and their progression slowed with conservative treatment — footwear changes, padding, splinting, and intrinsic muscle exercises. However, conservative care cannot “reverse” a deformity to normal anatomy without surgery. Rigid hammertoes (those that cannot be straightened) cannot be corrected without surgical intervention. Early treatment when the deformity is still flexible gives you the best chance of long-term non-surgical management.

What makes hammertoe worse?

The factors that most consistently accelerate hammertoe progression are: continuing to wear narrow or short shoes that force the toe to bend, weight gain that increases ground reaction force on the toe deformity, developing a bunion that crowds the second toe, ignoring an underlying flat foot that drives flexor over-recruitment, and avoiding treatment until the deformity becomes rigid. Skipping regular podiatric corn debridement causes the corn to thicken, increasing shoe pressure and accelerating joint irritation.

Is hammertoe hereditary?

There is a genetic component to hammertoe through inheritance of foot structure — flat feet, long second toe (Morton’s foot), bunion tendency, and certain neuromuscular conditions are all heritable and all predispose to hammertoe. However, hammertoe is not a directly inherited deformity in the same way a genetic disease is. Inheriting predisposing foot structure combined with environmental exposure to poor footwear is the most common combination. If a parent has hammertoes, evaluating foot structure early in life and choosing appropriate footwear can significantly reduce the risk of developing the same deformity.

When should I see a podiatrist for hammertoe?

See a podiatrist as soon as you notice a toe beginning to bend, even if it is not yet painful. Earlier evaluation allows assessment while the deformity is still flexible and treatment options are most numerous. See urgently if you have any skin breakdown over the corn, especially if you are diabetic. See if the toe is crossing over adjacent toes, if you cannot find comfortable footwear, or if pain is affecting your daily activities or exercise routine.

Does insurance cover hammertoe treatment?

Medicare and most private insurers cover hammertoe treatment — both conservative (office visits, custom orthotics with appropriate diagnosis, debridement) and surgical (when the deformity is painful, causing skin breakdown, or limiting function). Purely cosmetic hammertoe correction is not typically covered. Our office can verify your specific benefits and document medical necessity before treatment. Call (810) 206-1402 to confirm coverage before your visit.

Sources

1. Coughlin MJ, Saltzman CL, Nunley JA. “Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopaedic Foot and Ankle Society on angular measurements.” Foot & Ankle International. 2003;24(1):68–74.
2. Schrier JC, Verheyen CC, Louwerens JW. “Definitions of hammer toe and claw toe: an evaluation of the literature.” Journal of the American Podiatric Medical Association. 2009;99(3):194–7.
3. Deland JT, Lee KT, Sobel M, DiCarlo EF. “Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint.” Foot & Ankle International. 1995;16(8):480–6.
4. Boffeli TJ, Tabatt JA. “Minimally Invasive Early Operative Intervention for Flexible Hammertoe Deformity.” Journal of Foot and Ankle Surgery. 2016;55(4):765–71.
5. Harmonson JK, Harkless LB. “Operative procedures for the correction of hammertoe, claw toe, and mallet toe: a literature review.” Clinics in Podiatric Medicine and Surgery. 1996;13(2):211–20.

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your hammertoe, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.

Frequently Asked Questions

Will my bunion get worse over time?

In most cases, yes — gradually. Bunions are progressive deformities; without intervention, the metatarsal bone continues to drift outward over years. The rate of progression varies enormously: some bunions are stable for decades; others worsen significantly within 5 years. Wearing narrow, pointed-toe footwear accelerates progression. If your bunion is causing pain or limiting footwear choices and is still mild-to-moderate, earlier surgical correction has better outcomes than waiting for severe deformity.

Can I fix a bunion without surgery?

Conservative treatment manages symptoms but cannot structurally correct the deformity. Wide toe-box shoes, bunion pads, toe separators, and orthotics reduce pain and slow progression. They cannot realign the metatarsal bone because the deviation involves structural changes to the joint capsule and ligaments. If the goal is permanent cosmetic and functional correction, surgery is the only option. If the goal is pain management and living comfortably with the bunion, conservative care can be effective for years.

Can splints or bunion braces straighten a bunion?

No — this is one of the most common misconceptions. Bunion splints maintain toe alignment while being worn and may slow progression, but cannot reverse the bony deviation. The first metatarsal has physically rotated and shifted laterally — no external splint can move bone. Studies show splints worn nightly improve comfort and reduce inflammation but do not change bunion angle on X-ray. They’re a useful adjunct for pain management, not correction.

What causes bunions? Are they genetic?

Bunions have a strong genetic component — about 70% of patients with bunions have a first-degree relative with bunions. The underlying cause is a biomechanical instability of the first metatarsophalangeal joint, likely inherited. Footwear doesn’t cause bunions but accelerates them — tight, narrow shoes in a genetically predisposed person progress much faster than in someone who wears supportive shoes. Women develop bunions more often than men largely due to footwear choices over decades.

What shoes should I wear with a bunion?

Wide toe box is non-negotiable — the box must accommodate the bunion without compressing it. Avoid anything with a tapered or pointed toe, stiletto heels, or thin canvas uppers that press against the bump. Best options: Hoka Bondi, New Balance 574, Brooks Ghost (wide), Altra (all models have anatomical toe box). For dress occasions, Vionic and Orthofeet make supportive wide-toe options. The general rule: your toes should never feel compressed.

How long is recovery from bunion surgery?

Recovery depends on the procedure. Simple bunionectomy (soft tissue only): 4–6 weeks. Osteotomy (bone cut and realignment, the most common modern approach): 6–12 weeks non-weight-bearing in a boot, full recovery 4–6 months. Lapidus procedure (fusion at the base of the first metatarsal): 6–8 weeks non-weight-bearing, 6–9 months full recovery. The Lapidus has the lowest recurrence rate and is preferred for severe bunions or hypermobile first rays. We discuss the specific procedure during your surgical consultation.

Will I be able to walk after bunion surgery?

Yes — most patients walk in a surgical boot immediately or within 1–2 weeks. Full return to regular shoes takes 6–12 weeks depending on the procedure. Return to athletic activity typically takes 4–6 months. The question we hear most often is whether the foot will be comfortable and functional long-term — the answer is yes for the vast majority. Over 90% of patients are satisfied with bunion surgery outcomes at 5-year follow-up.

Can bunions come back after surgery?

Yes — recurrence is possible, especially without lifestyle changes. With modern osteotomy procedures, recurrence runs 5–10% at 10 years. The Lapidus procedure has the lowest recurrence rate (2–5%) because it addresses the hypermobility at the metatarsal base. The single biggest recurrence factor is returning to narrow, pointed-toe shoes within 6 months of surgery. We follow patients for 2 years post-surgery specifically to catch early recurrence signs.

Does insurance cover bunion surgery?

Most PPO and Medicare plans cover bunion surgery when it’s functionally necessary — meaning pain limits daily activity, conservative care has been attempted, and X-rays show a meaningful deformity. Purely cosmetic bunionectomy is not covered. We document conservative treatment failure and functional limitation prior to surgery to build the strongest possible insurance case. Call our office at (810) 206-1402 and we’ll verify your coverage before your consultation.

Can children get bunions?

Yes — juvenile bunions account for about 10% of all bunions and are typically bilateral and genetic. They’re most common in girls aged 10–15. Treatment in growing children is conservative whenever possible — wide-toe-box shoes and monitoring. Surgical correction is generally delayed until skeletal maturity (16–18) because operating on open growth plates increases recurrence risk. If your child has a painful or rapidly progressing bunion, evaluation is warranted to track progression.

OrthoInfo – AAOS: Hammer Toe

When is bunion surgery actually necessary?

Surgery is appropriate when: pain is consistent and limits daily activities despite 3–6 months of conservative care, footwear options are severely restricted, there’s a secondary deformity (hammer toe, crossover toe) being driven by the bunion, or joint arthritis is developing. Mild, painless bunions don’t require surgery even if they look significant on X-ray. The decision is always functional, not cosmetic — we operate on pain, not appearance.