Brian C. Toolan MD
Orthopaedic Foot and Ankle Surgery
The University of Chicago
Section of Orthopaedic Surgery and Rehabilitation Medicine
5841 S. Maryland Ave. sMC 3079 s Chicago s Illinois 60637
Phone 773.702.6984 Fax 773.702.0076
Hammer Toe
A hammer toe is a deformity of the second, third, fourth and fifth toes. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Initially, hammer toes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.
People with hammer toe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.
Causes of hammer toe
Hammer toe results from shoes that don't fit properly or a muscle imbalance, usually in combination with one or more other factors. Muscles work in pairs to straighten and bend the toes. If the toe is bent and held in one position long enough, the joint stiffens, muscles tighten and cannot stretch out.
Shoes that narrow toward the toe may make your forefoot look smaller. But they also push the smaller toes into a flexed (bent) position. The toes rub against the shoe, leading to the formation of corns and calluses, which further aggravate the condition. A higher heel forces the foot down and squishes the toes against the shoe, increasing the pressure and the bend in the toe. Eventually, the toe muscles become unable to straighten the toe, even when there is no confining shoe.
Treatment for hammer toe
Conservative treatment starts with new shoes that have soft, roomy toe boxes. Shoes should be one-half inch longer than your longest toe. (Note: For many people, the second toe is longer than the big toe.) Avoid wearing tight, narrow, high-heeled shoes. You may also be able to find a shoe with a deep toe box that accommodates the hammer toe. Or, a shoe repair shop may be able to stretch the toe box so that it bulges out around the toe. Sandals may help, as long as they do not pinch or rub other areas of the foot.
Your doctor may give you Orthotics or small splints to help to correct the hammer toe. Some of the options will be budin splints, or hammer toe crest pads.
Your doctor may also prescribe some toe exercises that you can do at home to stretch and strengthen the muscles. For example, you can gently stretch the toes manually. You can use your toes to pick things up off the floor. While you watch television or read, you can put a towel flat under your feet and use your toes to crumple it.
Surgery
If your hammer toe is fixed, or not flexible, you may need surgery to correct the hammer toes. This involved making incisions over each affected toe and doing a combination of any of the following: tendon, ligament and bone work to correct the toe. Sometimes the tendons have an imbalance causing a hammer toe, so to correct them, you equalize the balance. To do this, one of the tendons is lengthened and the other one shortened. Sometimes the ligaments need to be released because they are cause of the deformity. Bony work might include removing part of the bone from the toe.
After the work has been accomplished to straighten your toes, they will be held in that position with pins. The pins will be visible sticking out of the toes. This is to ensure that they heal properly. After surgery your toes will be straight but they will be stiff. Yoku will have motion at the joint where your toe connects to the foot. Hammer to surgery is effective, but sometimes they can come back.
Post operative management
There are many factors that affect your healing time. The most important is to be patient. YOUR FOOT MAY NOT TOUCH THE GROUND for the first 4-6 weeks after surgery. This is the amount of time it takes for the bone work to heal. This means you must use assistive devices, like crutches, a walker or roll-a-bout to get around. We do not want you to use a wheel chair because your entire body gets weak and it will lengthen your recovery time.
Another factor is smoking. YOU MUST NOT SMOKE while you are recovering. It will delay your healing. This includes second hand smoke. Smoking decreases the blood flow to your surgical site. This means that oxygen and nutrients essential for healing are decreased and will lengthen your recovery. It is also possible that the bones will not heal, or your wound will not heal and the skin dies. In the event that the bones do not heal, you will require additional surgery to get the bones to heal.
Another factor is swelling. This is something that can be avoided by elevating your foot above heart level. Swelling can also be controlled with ice therapy. Icing for 20-30 minutes in intervals will significantly decrease your swelling. The best thing to use for ice therapy is crushed ice or frozen vegetables because they can conform around your cast or splint. By eliminating swelling, you can reduce or eliminate your pain.
Pain management
The first 2-3 days after surgery will be the worst. You will have both swelling and pain. During this time it is very important that you decrease your activity level, elevate the operated foot above heart level, and use ice therapy. You will notice when you put your foot down, it will begin to swell immediately and you will experience a throbbing pain. To treat this, elevate and ice and it should go away. Over the next two weeks, you will be able to increase the amount of time you can have your leg down. It is still important to keep your leg elevated as much as possible.
After surgery, you will be given a prescription for pain medication. You should not need any refills. If you are out of pain medication, perhaps you are being too active and need to decrease your activity level. Before taking a pain pill, we suggest that you elevate and ice your foot 20-30 minutes for pain control first. If elevation and ice do not adequately control the pain, you may then take your pain medication. It is important to only take your pain medication when you need it. Just because the prescription says you may take it every 4-6 hours, does not mean that you have to.
Casting
After surgery you will be placed in a cast or splint. There is a handout on cast care. One important thing is to wiggle your toes 10 times an hour while awake to prevent stiffness. You will be in a cast for at least 4- 6 weeks.
Two weeks after surgery, you will return to the clinic. Your cast will be removed, and your stitches will be taken out. We will inspect the incision and steri-strips (like band aids) will be placed on the skin. You will be placed in a lighter weight fiberglass cast. You must still remain non-weight-bearing.
Four to Six weeks after surgery you will return to the clinic for a cast removal and x-rays. Your pins will be removed. If x-rays demonstrate that the bone is healing, you will not need another cast, and will be placed in a CAM Boot, which is like a big ski boot. A CAM Boot is a boot that can be removed for bathing and physical therapy. It must still be treated like a cast and worn at all times, including at night. If the x-rays demonstrate that the bone still needs time to heal, then you will be put in a cast for another 4 weeks. Then x-rays will be taken again to assess the bone healing, and the decision for casting or a CAM Boot will be made.
Physical Therapy
When you are placed in a CAM Boot, you cannot walk on it right away. You will begin at 30-50 pounds of weight bearing with crutches/walker. This is simply putting the leg down and supporting the weight of the leg only. You will now start physical therapy 2-3 times a week for 6-12 weeks to progress to full-weight-bearing without crutches. After full weight bearing has been achieved, you will be weaned out of your CAM Boot into your regular shoes.
During therapy, you will work on strengthening, mobility and gait training. At three months, after surgery you should be independent with activities of daily living, but should expect continued swelling. You will continue to work on the therapy you have learned at home.
At 10-12 weeks after surgery, you will return for a clinic appointment. You will be evaluated to see how well the correct hammertoes have healed. You may be able to return to work without any restrictions.
It is important to remember that you may still have good and bad days after your treatment is completed. It can take up to six months to return to your normal level of activity. Although there will be some bad days, over time you will get progressively better. We will see you back at the six month anniversary of your surgery. At six to nine months, the foot should “feel normal”, range of motion is greatly improved, swelling is decreased and there are no problems with the foot with normal activities.
At any time during your treatment, you may call the office at (773) 702-6984 with any questions or concerns.