Hammertoe (claw or hammer deformity) treatment

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What is it?

Hammertoe is a common disorder of the toes mainly affecting women over the age of 50. Based on the shape of the toes, it is referred to as a claw or hammer deformity, depending on the joints affected. With the development of knowledge on the subject, this classification is gradually losing its relevance and the focus is now on determining the flexible, semi-rigid or rigid nature of the deformity, depending on the ability of the toe to easily recover its normal position.

The toe is normally in the extended position of its own joints and is essentially dependent on the balance of the tendons in the foot. Tendons attached to the phalanges ensure the mobility of the different joints and, via traction, these allow the flexion or extension of each joint. It is a delicate balance in which each tendon must receive compensation from the others so the toe remains in its normal resting position.

If one of these tendons is more powerful or has simply become shortened, a deformity is soon observed in flexion or extension positions due to the imbalance between the tendons and the body’s inability to compensate for the retraction. The shape of the toe will then depend on the tendon(s) affected.
Most often, the first sign is a retraction of the toe’s flexor muscles, which will trigger a flexion of the first interphalangeal joint. A deformity of the metatarsophalangeal joint may develop after this, at the base of the toe, and this is what gives the toe its characteristic hammer-like shape. In this position, the toe will rapidly feel uncomfortable when wearing shoes due to the excess pressure between the interphalangeal joint and the shoe. A corn (or callus), which is basically a thickening of the skin to protect the toe from this pressure (see Fig. 1), will then develop.

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  • Fig. 1

    Hammertoe with retraction of the flexor and extensor tendons. The deformity produces a corn on the dorsal part of the toe (flexion of the interphalangeal joint, extension of the metatarsophalangeal).

Although the joint deformity can initially be reduced, it will gradually result in stiffening and become increasingly difficult to bear. Finally, a dislocation of the base of the toe may be observed. This type of case represents the most severe form and usually causes pain under the foot.

Although these deformities can present in an isolated form, they are generally linked to other conditions. The most common condition is hallux valgus (bunion) which systematically leads to an overloading of adjacent toes and greatly facilitates the retraction of the toe tendons and therefore their deformity. Other sources of hammertoe include high arches, neuropathy of the foot, rheumatoid arthritis, etc. Wearing high heels, incorrect footwear, or having a Greek foot (that is, when the second toe is longer than the first) are other circumstances that may facilitate the development of hammertoe, either due to the incorrect position of the toes in shoes or an overloading of the forefoot.

Clinical presentation

The dorsal pressure of the toe in the shoe is usually the first complaint. With rigid deformities, the corn may suffer an injury and form an ulcer or become infected. This is an important warning sign, especially in diabetic patients whose toes are major sources of complications.

Severe cases of hammertoe result in changes to the pressure at the terminal point of the toe. Normally, at the tip of the toe the load is carried by the fleshy part (toe-to-ground support). With hammertoes, the toe presses down on the most terminal section (apical support) which is totally unsuited for this purpose and causes very severe pain.

Finally, when the metatarsophalangeal joint is affected, joint pain (second digit syndrome) is often experienced due to the instability of the joint. If this instability progresses, partial dislocation followed by complete dislocation of the phalanx may occur. In such cases, significant pressure is then passed on to the metatarsal head and increases the load at this level, triggering a classic case of metatarsalgia.

When should you consult a specialist?

When the hammertoe causes painful pressure in the shoe or when the metatarsophalangeal joint becomes sensitive, it is highly advisable to consult a specialist.

The toes of diabetic patients require regular monitoring and they must consult whenever skin lesions or injuries occur.

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