Drs Raymond & Laura Soluri      

Hammertoes    

WHAT'S THE PROBLEM?
Hammertoe is the general term used to describe an abnormal contraction or "buckling" of the toe because of a partial or complete dislocation of one of the joints of the toe or the joint where the toe joins with the rest of the foot. As the toe becomes deformed, it rubs against the shoe and the irritation causes the body to build up more and thicker skin to help protect the area. The common name for the thicker skin is a corn. At first, this thick skin helps reduce irritation to the bone prominence, but as the skin becomes thicker, it adds to the pressure from the shoe. Periodic trimming of the corn may give temporary relief. However, over a period of time, a bursa may develop and if it becomes inflamed (bursitis), the area becomes red, swollen and painful. It may also become infected. There are two joints in the lesser toes and one joint in the great toe. If the deformity occurs in the joint nearest the nail, it is called a mallet toe and the corn will usually develop on the tip of the toe. This is due to the pressure being on the tip of the last toe bone rather than at the fat pad under the tip of the toe. If the deformity is at the other toe joint, or where the toe joins the foot, it is called a hammertoe and the corn will occur on the top of the toe. Corns may also develop between toes. These are usually due to a rotation of the toe, rather than a contraction (buckling). This can cause the joints to rub together and may create small bone spurs that cause corns in a similar manner. Do not confuse corns with calluses that occur on the bottom of the feet. They are generally caused by other conditions, although a severe hammertoe may create downward pressure on a metatarsal bone at the ball of the foot, and add to the cause of a callus.

HOW DOES IT FEEL?
A hammertoe may be present but not always painful unless irritated by shoes,. One may have enlarged toe joints with some thickened skin and no redness or swelling. However, if shoes create pressure on the joint, the pain will usually range from pinching and squeezing to sharp and burning. Cramping in the toes, foot and leg may develop from the muscles and tendons functioning in abnormal positions because of the deformed joints. In long standing conditions, the dislocated joints can cause the pain of arthritis.
 

LETS DO A TEST
The diagnosis of hammertoes is initially made by a simple exam of your feet. X-rays may be necessary to evaluate the severity and type of deformity. Additional lab tests may be necessary to rule out infection or other medical conditions.

HOW DID THIS HAPPEN?
Although there is little doubt shoes are responsible for causing corns, the size, shape and other characteristics of our feet are hereditary. The contraction and/or rotation of toes can be the result of poor mechanics of the foot, resulting in over-pronation. This results in low or flat arches, which cause the muscles and tendons of the foot to twist the toes and joints away from their normal position. High arched feet (over-supination) can also result in similar conditions. A severe bunion may cause a hammertoe, as the great toe twists over or under the second toe, causing it to dislocate. Shoes cause the corn, as the bony top of the toe rubs on the toe box of the shoe, but the underlying problem is the abnormal position of the toe joints, which may be hereditary. The crooked toe is irritated by shoe pressure on the joint or spur. As a result, the skin becomes thicker to form a protection. The thicker the skin, the more pressure and eventually, a bursitis under the corn may develop. This causes the joint to become red, swollen and painful. Additionally, the skin can break down and become infected.

WHAT CAN I DO FOR IT?
The most important thing is to purchase well fitted, comfortable, low heeled shoes that do not irritate the crooked toe. Also, make sure your stockings are not tight, causing the toes to contract. High heel shoes should be worn at a minimum, as they cause the tendons of the toes to pull them up into an contracted position. Tennis type and walking shoes have significantly decreased the complaint of many people with hammertoe deformities. Although the crooked toe is still present, it may not hurt if the shoe is large enough.

BATH TUB SURGERY IS NOT A GOOD IDEA!
Trimming corns with a razor blade may give temporary relief, but is dangerous, as you can cut yourself and cause an infection. Non-medicated pads from the drug store do give relieve from shoe pressure and are helpful. However, if the toe becomes red and swollen, consult with your family podiatrist right away.

WHAT WILL MY DOCTOR DO FOR IT?
Your doctor will examine you and make a differential diagnosis. That is, decide what type of hammertoe you have and rule out other medical conditions. Treatment may range from more appropriate footgear to periodic trimming and padding of the corn. Cortisone injections may be indicated if a bursitis is present. Antibiotics may be utilized in the presence of infection. Removable accommodative pads may be made for you. If conservative treatment is unsuccessful, surgical intervention may be suggested. In the early stages, when the toe joints are flexible, this may involve a minor procedure, such as cutting or lengthening the tendons to straighten the toe. If the toe is relatively straight and the corn is caused by pressure on a spur, the enlarged bone may be remodeled and the spur removed. In more advanced cases, when the joint is dislocated, part of the bone at the joint may be removed. Temporary pins may be used to keep the toe straight while it is healing. Sometimes, the removed bone is replaced with a synthetic joint implant, to straighten the toe and help it function properly.

Most of these toe surgeries are performed  in a hospital's ambulatory surgery unit utilizing local anesthesia with IV sedation. A special stiff soled shoe is used so you can walk right away.

CAN I PREVENT IT FROM HAPPENING AGAIN?
After either conservative treatment or surgery, follow your doctor's orders, which may include advice regarding proper footgear, minimal use of high heel shoes, accommodative padding, or an orthotic worn inside the shoe to balance and improve the function of your feet.