Hammertoe Surgery: Flexor Tenotomy, PIP Fusion, and MTP Arthroplasty — Choosing the Right Procedure

What is a hammertoe — and the three deformity patterns

“Hammertoe” gets used as a catch-all for any bent lesser toe, but there are actually three distinct deformity patterns and the treatment differs for each:

• Hammertoe (true): The middle joint (PIP) is bent downward. The end of the toe points down. This is by far the most common pattern — particularly in the 2nd toe.
• Claw toe: The toe knuckle (MTP) is hyperextended AND the middle joint (PIP) is bent. The toe looks like a claw. Often bilateral. Frequently associated with neuropathy, RA, or pes cavus.
• Mallet toe: Only the distal joint (DIP) at the very tip is bent. Tip of the toe presses into the shoe. Most common in the 2nd toe in patients with a long 2nd toe.

The other key distinction is whether the deformity is flexible (you can manually straighten it) or rigid (it’s stuck). Flexible deformities have many more conservative options and respond to simpler surgeries (like a flexor tenotomy). Rigid deformities have lost cartilage in the bent joint and need a fusion or arthroplasty to truly correct.

Why hammertoes form — and why they progress

Hammertoes are mechanical. The underlying problem is almost always an imbalance between the muscles that flex the toe down and the ones that extend it up. The most common contributors I see in clinic:

• Long 2nd toe (Greek foot pattern): The 2nd toe is longer than the great toe, gets jammed against shoe toe-boxes, and develops a contracture over years.
• Bunion (HAV) deformity: The great toe drifts laterally into the 2nd toe, displacing it upward and creating a “cross-over toe” with hammer deformity.
• Pointed-toe or high-heeled shoes: Years of compression in narrow toe-boxes forces the toes into flexion. Heavily overrepresented in female patients.
• Neuropathy: Diabetic and other peripheral neuropathies cause intrinsic foot muscle wasting, which unmasks the flexor-extensor imbalance and creates claw toe deformities.
• Inflammatory arthritis (RA, psoriatic): Synovitis at the MTP joint causes dorsal subluxation and a claw-toe pattern.
• Cavus (high-arched) foot: Naturally creates more pull on the long flexors, contributing to claw toes.

The thing patients don’t want to hear: hammertoes do not improve on their own. They progress slowly from flexible to semi-rigid to rigid over years. The earlier you catch them, the simpler the correction.

Conservative care — what reduces symptoms without fixing the deformity

Non-surgical care for hammertoes doesn’t reverse the deformity — but it can reduce pain, prevent skin breakdown, and slow progression. What I recommend in actual clinic, ranked by effectiveness:

Wider toe-box shoes

The single most effective conservative measure. A deep toe-box (round or “anatomical” toe shape) with at least a thumb’s-width of room beyond your longest toe eliminates the friction that drives 80% of hammertoe pain. Brands I commonly recommend: New Balance widths 2E/4E, Hoka with the “Wide” designation, Brooks Beast/Glycerin in wide, Vionic walking lines, Altra zero-drop natural foot shape. Avoid pointed toe-boxes entirely.

Gel toe sleeves and crest pads

Silicone gel sleeves cushion the PIP knuckle against the shoe and prevent callus formation. Crest pads (a small pad worn under the toes) can passively elevate the toe tips off the floor and reduce pressure on the tips. These are first-line for any patient with hammertoe pain — they’re cheap, available OTC, and provide immediate relief.

Toe spacers and straighteners

Gel toe separators help mainly when the hammertoe is caused by adjacent bunion pressure (crossover-toe pattern). Hammertoe “straightener” splints worn at night marginally maintain flexibility in early flexible deformities but do not permanently correct them. Honest assessment: useful for delaying surgery in select patients, not a real fix.

Custom orthotics with metatarsal pad

For patients whose hammertoes are accompanied by ball-of-foot pain (metatarsalgia), custom orthotics with a metatarsal pad redistribute pressure off the MTP joints and reduce pain by 50-70% in my experience. Doesn’t correct the toe deformity but addresses the secondary forefoot pressure problem.

Routine callus debridement

For patients with hammertoe-related calluses on the PIP knuckle or toe tip, professional debridement every 8-12 weeks prevents ulceration and dramatically reduces pain. This is the single most important intervention for hammertoes in diabetic patients.

Surgical correction — three procedures by deformity stage

Hammertoe correction is one of the most rewarding operations I do because the outcome is so predictable when the right procedure is matched to the right deformity. The three core operations:

Flexor tenotomy — for flexible hammertoes

The procedure: a percutaneous (no-incision) release of the flexor tendon under the toe through a 2mm needle puncture. Done in the office under local anesthesia in about 5 minutes per toe. No stitches, no cast, no boot — patients walk out in a surgical sandal and back to normal shoes within a few days.

Outcomes: studies of percutaneous flexor tenotomy for diabetic forefoot ulcers show ulcer healing rates of 90%+ at 3 months and hammertoe correction rates of 80-90% at 1 year. A 2014 meta-analysis in Diabetic Medicine confirmed flexor tenotomy as a safe, effective ulcer-prevention procedure in this population. For non-diabetic patients with flexible hammertoes, the correction rate is similar.

I use this procedure for: flexible hammertoes (especially in diabetic patients or as a preventive measure before ulceration), painful flexible 5th-toe deformities (corns from shoe rub), and as part of multi-toe corrections when most toes are still flexible.

PIP arthrodesis (fusion) — for rigid hammertoes

The procedure: small incision over the top of the PIP joint, removal of the arthritic cartilage from both sides, and fusion of the two bones in a straight position. Most modern surgeons use an internal implant (intramedullary K-wire, a small titanium implant like the Smart Toe or Hammerlock, or absorbable PEEK device). No external pin sticking out of the toe anymore (in most cases).

Outcomes: PIP fusion has 90%+ patient satisfaction rates in published series. A 2018 systematic review of intramedullary implants for hammertoe correction found bony union rates of 75-90% and patient satisfaction rates of 85-95%. The toe is permanently straight and the deformity does not recur. Trade-off: you lose motion at the fused joint (which most patients don’t notice — there’s not much PIP motion in a hammertoe anyway).

I use this procedure for: rigid hammertoes that have lost flexibility, semi-rigid deformities that have failed conservative care, and any hammertoe in a patient who wants a definitive correction.

MTP arthroplasty / Weil osteotomy — for severe or claw-toe deformities

When the deformity isn’t just at the PIP but also at the MTP joint (claw toe, dislocation at the knuckle), simple PIP fusion isn’t enough — the toe is still pointing up. In these cases I combine PIP fusion with a Weil osteotomy (shortening cut of the metatarsal neck) and/or an MTP joint release to seat the toe back into proper alignment. The combined procedure has slightly more recovery time but is the only way to address full claw-toe deformity definitively.

Recovery — what to expect after surgery

One of the most surprising things to patients is how light the recovery actually is for hammertoe correction compared to bunion or rearfoot surgery:

• Day 0 (surgery day): Walk out in a stiff post-op shoe or surgical sandal. Local anesthesia wears off within 4-6 hours.
• Week 1: Keep foot elevated. Sutures may dissolve or come out at week 2. Most patients use only over-the-counter pain medication after day 2-3.
• Week 2-4: Continued use of post-op shoe. Swelling subsides. X-ray at 4-6 weeks to confirm bone healing (for PIP fusion).
• Week 4-6: Transition back to normal athletic shoes. Most patients are doing full daily activities including driving and work (desk-job).
• Week 8-12: Return to running, jumping, and high-impact activities. Final toe shape settles around 3 months. Mild residual swelling can persist for 6 months.

For flexor tenotomy specifically, recovery is even faster — most patients return to normal shoes within 5-7 days and full activity within 2 weeks. There is no bone healing required because nothing was cut.

Risks and how I minimize them

Common but minor:

• Persistent swelling: Forefoot swelling can persist for 3-6 months. Normal and expected. Elevation, ice, and compression hose help.
• Toe stiffness: Some PIP fusion patients notice the toe is stiff post-op. After 3-6 months this becomes invisible to daily activities.
• Numbness at the toe tip: Small skin nerves can be irritated; usually resolves within 6 months.

Uncommon but important:

• Nonunion (PIP fusion): 5-15% in published series. Often asymptomatic (“fibrous union”). Revision surgery occasionally needed.
• Recurrence: Higher with flexor tenotomy in rigid deformities (which is why proper patient selection matters) and higher when there’s an uncorrected adjacent bunion pulling the toe back.
• Floating toe: A risk after Weil osteotomy — the toe doesn’t touch the floor properly afterward. Reduced with proper plantar plate repair and modern technique.
• Infection: <1% with modern technique and pre-op antibiotic prophylaxis.

When to see a podiatrist — Howell & Bloomfield Hills appointments

See a podiatrist for hammertoe evaluation if:

• You have pain on top of the toe knuckle that interferes with shoe fit
• You have calluses or corns forming on a bent toe
• You have diabetes and are noticing your toes are starting to bend
• Your bunion is now pushing your 2nd toe up and over
• The deformity is progressing — getting more bent over months/years
• You’ve tried wider shoes, padding, and toe sleeves and still have pain

At Balance Foot & Ankle, hammertoe evaluation includes a hands-on flexibility test (flexible vs. rigid determines the procedure), weight-bearing X-rays if surgical correction is being planned, and review of your shoe-fit and any underlying conditions (neuropathy, RA, cavus). Flexor tenotomy is performed in-office under local anesthesia in 10-15 minutes total chair time. PIP fusion and combined corrections are performed by Dr. Tom Biernacki, DPM, FACFAS at our outpatient surgery center.

Frequently asked questions

Can hammertoes be fixed without surgery?

Symptoms can be managed without surgery — pain, calluses, and shoe-fit issues respond well to wider shoes, gel pads, and orthotics. But the deformity itself does not reverse without a procedure. Splints and toe straighteners do not permanently correct an established hammertoe in adults. If the deformity is bothering you cosmetically or functionally and conservative care has plateaued, surgical correction is the only definitive option.

How long does hammertoe surgery take?

Flexor tenotomy: about 5 minutes per toe, done in the office. PIP fusion: about 20-30 minutes per toe in the operating room. Combined corrections with multiple toes or Weil osteotomies can take 60-90 minutes total. All hammertoe corrections are outpatient — you go home the same day.

Will I have a pin sticking out of my toe?

Almost never with modern technique. We use internal implants (small titanium or absorbable implants that stay inside the bone) rather than external K-wires for the vast majority of PIP fusions. External pins are largely outdated outside of specific revision cases.

Does insurance cover hammertoe surgery?

Yes — when there is documented pain, callus formation, ulceration risk, or failed conservative care. Most major insurance plans cover hammertoe correction as medically necessary in these circumstances. Purely cosmetic correction (no pain, no functional issue) is not covered. Our team handles pre-authorization and documentation.

Can I drive after hammertoe surgery?

For right-foot surgery: typically week 3-4, once you’re transitioned out of the post-op shoe. For left-foot surgery (automatic transmission): often within 1 week. After flexor tenotomy: most patients drive within a few days. Always check with your surgeon before resuming driving.

Will my hammertoe come back after surgery?

PIP fusion: recurrence is essentially zero because the joint is fused. Flexor tenotomy: 10-20% may have partial recurrence at 5 years, typically not severe. The bigger risk factor for recurrence is an uncorrected adjacent bunion pulling the toe back — if you have a significant bunion with a hammertoe, both usually need to be addressed at the same time for durable correction.

What’s the difference between hammertoe and bunion?

A bunion is a deformity of the great toe joint (1st MTP) — the big toe drifts laterally and the metatarsal head bumps outward. A hammertoe is a contracture of a lesser toe (usually 2nd-5th). They commonly occur together because a bunion pushes the 2nd toe up and over, creating a “crossover toe” hammertoe pattern. Both can be corrected at the same operation.

The bottom line

Hammertoes don’t reverse on their own — but they do progress, and the longer you wait, the bigger the surgery. If you have a flexible hammertoe causing pain or shoe-fit problems, a 5-minute office flexor tenotomy can correct it without a cast, a boot, or time off your feet. If it’s already rigid, PIP fusion delivers a permanent straightening with 90%+ patient satisfaction and a 4-6 week recovery to normal shoes. The procedure that’s right for you depends almost entirely on whether the joint is still flexible — and that’s a 60-second hands-on exam, not an MRI question.

— Dr. Tom Biernacki, DPM, FACFAS

Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a board-certified foot & ankle surgeon (ABFAS & ABPM) at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has made him one of the most-followed foot & ankle educators on YouTube.