Hammertoes — Causes, Flexible vs. Rigid Deformity, and Treatment

Related Conditions

✅ Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist · Last updated April 6, 2026

Hammertoes — Causes, Flexible vs. Rigid Deformity, and Treatment

Hammertoes — Causes, Progression, and Treatment Options

Hammertoe is a deformity of one or more of the lesser toes (second through fifth) in which the toe bends abnormally at the proximal interphalangeal (PIP) joint, creating an upward arch that resembles a hammer. The deformity is progressive — it typically begins as a flexible deformity that can be manually straightened, and advances over years to a rigid, fixed deformity that no longer corrects with external pressure. Early intervention during the flexible stage offers the most treatment options and the least invasive solutions.

What Causes Hammertoe Deformity

Hammertoes develop from a muscle-tendon imbalance in the toe. The intrinsic muscles of the foot that should stabilize the toe’s position are relatively weak, allowing the long flexor and extensor tendons to dominate — pulling the toe into the characteristic bent position. Contributing factors include: shoes too short or too narrow (forcing the toe into a bent position for prolonged periods), flat feet (which alter toe mechanics), underlying neuromuscular conditions, and in the second toe specifically, a first MTP joint problem like bunion or hallux rigidus that causes the second toe to be pushed from its normal position by the first toe.

Flexible vs. Rigid Hammertoe

The distinction between flexible and rigid hammertoe is clinically critical because it determines treatment options. A flexible hammertoe can be manually straightened — the joint cartilage and capsular structures have not permanently contracted. Conservative treatment including toe exercises, appropriate footwear, and toe separators or splints can slow or halt progression in flexible hammertoes. A rigid hammertoe cannot be straightened manually — the joint structures have permanently contracted into the deformed position. Rigid hammertoes cannot be corrected conservatively and require surgical correction if the deformity is symptomatic and limiting.

Conservative Management

For flexible hammertoes, conservative management focuses on reducing symptoms and slowing progression. Wide toe-box footwear with a deep toe box prevents dorsal rubbing of the PIP joint against the shoe upper — the most common source of hammertoe pain. Silicone hammertoe pads or caps cushion the prominent joint. Toe splints worn at rest hold the toe in a straighter position and may slow structural progression. Exercises that strengthen the intrinsic muscles — towel scrunches, marble pickups, toe spreads — address the underlying muscle imbalance that drives deformity progression. These measures provide symptomatic relief but do not reverse established deformity.

Surgical Options

When conservative management fails to control symptoms, surgical correction is considered. For flexible hammertoes, a flexor tendon transfer procedure — releasing the tight flexor tendon and transferring it dorsally — can straighten the toe without removing bone. For rigid hammertoes, the standard procedure is PIP joint arthroplasty (removing a small wedge of bone from the joint head, allowing the toe to straighten) or arthrodesis (fusing the joint in a straightened position). K-wires or small screws maintain the corrected position during healing. Surgery is typically performed as day surgery under ankle block anesthesia, with recovery involving protected weight-bearing for 4 to 6 weeks.

Preventing Progression in Early Hammertoe

Early hammertoe detected while still flexible offers the best opportunity for conservative management to be meaningful. Switching to wide, deep toe-box footwear immediately reduces the driving force of shoe compression. Addressing co-existing bunion deformity that may be pushing the second toe out of position is equally important. Beginning toe strengthening exercises early, before significant muscle atrophy has occurred, builds the intrinsic muscle capacity needed to resist further deformity. Regular podiatric follow-up tracks whether progression is occurring despite conservative measures, allowing timely surgical referral before rigid deformity makes the procedure more complex.

Hammertoe vs. Mallet Toe vs. Claw Toe: Understanding the Difference

The terms hammertoe, mallet toe, and claw toe are frequently used interchangeably by patients but describe distinct deformity patterns that differ in which toe joints are affected. A true hammertoe involves flexion contracture at the proximal interphalangeal (PIP) joint — the middle knuckle — with the distal interphalangeal (DIP) joint and metatarsophalangeal (MTP) joint in relatively normal position. The toe buckles at the middle joint, creating a raised prominence that rubs against shoe material.

Mallet toe affects only the distal interphalangeal joint — the joint closest to the toenail. The tip of the toe curls downward, creating a callus on the tip of the toe rather than the top of the middle joint. Claw toe involves flexion at both the PIP and DIP joints simultaneously, with hyperextension at the MTP joint — the most complex of the three deformities, and the one most commonly associated with systemic neuromuscular conditions (Charcot-Marie-Tooth, diabetes-related neuropathy) as well as severe chronic cavus deformity. The distinction matters clinically because each deformity pattern is corrected by a different surgical approach targeting the specific contracted joint. Accurate pre-operative diagnosis ensures the correct procedure is performed. At Balance Foot & Ankle in Howell and Bloomfield Township, our podiatric surgeons assess each lesser toe deformity individually to determine the precise deformity pattern and the targeted correction it requires.

---

Related Treatment Guides

• Plantar Fasciitis & Heel Pain Treatment
• Custom 3D Orthotics
• Sports Foot & Ankle Injury Treatment
• Bunion Treatment

Michigan patients experiencing foot or ankle problems can schedule an appointment at Balance Foot & Ankle — with locations in Howell (4330 E Grand River) and Bloomfield Township (43494 Woodward Ave #208). Call (810) 206-1402 for same-week availability.

In-Office Treatment at Balance Foot & Ankle

If home care isn’t resolving your hammertoe, a visit with a board-certified podiatrist is the fastest path to accurate diagnosis and a personalized plan. At Balance Foot & Ankle Specialists, Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin offer same-day and next-day appointments at both our Howell and Bloomfield Township offices. We perform on-site diagnostic ultrasound, digital X-ray, conservative care, advanced regenerative treatments, and minimally invasive surgery when indicated.

Call (810) 206-1402 or request an appointment online. Most insurance plans accepted, including Medicare, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare.

Differential Diagnosis: What Else Could It Be?

Several conditions share symptoms with Hammertoe and are commonly misdiagnosed in the first office visit. Considering these alternatives is part of every Balance Foot & Ankle exam:

• Mallet toe. Bend at the distal joint only (DIP), not the middle joint.
• Claw toe. Both joints (PIP + DIP) bent — usually multiple toes, often diabetic.
• Crossover toe (2nd MTP). Drift across the big toe — often plantar plate tear underneath.

If your symptoms don’t fit the textbook pattern, ask your podiatrist which differentials they ruled out — that conversation often shortcuts months of trial-and-error treatment.

Most Common Mistake We See

The most common mistake we see is: Cutting corns at home with scissors or razors. Fix: professional podiatric enucleation with sterile instruments prevents infection and recurrence.

Warning Signs That Need Same-Day Care

More questions patients ask

What is a hammertoe?

A hammertoe is a deformity where the toe bends abnormally at the middle joint, creating a hammer-like appearance. It typically affects the second through fifth toes and results from muscle imbalance, tight shoes, genetics, or underlying conditions like arthritis. Without treatment, flexible hammertoes become rigid and may require surgical correction. Dr. Biernacki offers both conservative and surgical treatment options.

Can hammertoes be fixed without surgery?

Flexible hammertoes (those that can still be straightened manually) often respond to conservative treatment including toe splints, padding, shoe modifications, custom orthotics, and stretching exercises. Once a hammertoe becomes rigid, surgery may be necessary. Early intervention provides the best outcomes for non-surgical management.

What does hammertoe surgery involve?

Modern hammertoe correction typically involves a minimally invasive approach where Dr. Biernacki releases the contracted tendon and removes a small bone segment through a tiny incision. Recovery involves wearing a surgical shoe for 3-4 weeks with most patients returning to regular shoes within 6 weeks. Success rates exceed 90% with low recurrence rates.

Still have a question about coverage or cost? Book online and we will check your benefits before your visit: Book in Howell · Book in Bloomfield Township. Prefer to talk it through first? Call (810) 206-1402.