Many patients ask me, "Why are my toes no longer straight?" Depending on your foot type as well as ankle and knee position, the cause may be readily apparent or be a bit of mystery. In my family a curled under 4th and 5th toe is genetic. (Toes are counted from the big toe out, so the pinky toe is number 5.)
Hammertoes can come in various forms but there are three basic types:
1. Hammertoe: contracture is at the joint furthest from the tip of the toe.
2. Clawtoe: contracture is at both joints in the toe.
3. Mallet toe: contracture is at the joint closest to the tip of the toe.
Most podiatrists would agree that the cause of hammertoes is not straightforward and is very individualized. As mentioned before, it can be a genetic problem, secondary to trauma and disease such as rheumatoid arthritis and diabetes, due to poor mechanical positioning of the arch, poor walking mechanics and poorly fitting shoes. Bunion deformities may help create hammering of nearby digits because of crowding and positional changes. The list goes on and on.
Can hammertoes be prevented? Very difficult to say. If you knew that it ran in your family and everyone before you had loved a certain type of shoe, say aggressive high heels, then yes avoiding these shoes might make a difference. Usually patients don't notice until it's too late. By too late I mean, conservative treatments are only going to help with symptoms but rarely will they actually fix the hammertoes long term.
Complications from Hammertoes:
Hammertoes can be responsible for shifting the much needed fat pad at the ball of the foot forward so that the patient is actually walking on skin and bone alone resulting in significant pain. The deformity when combined with a foot that is numb (insensate) say from diabetes or back injuries can result in wounds that are chronic and difficult to treat often resulting in amputation. For some people, hammertoes can be a serious cosmetic problem (for the more vain amongst us) or a real source of pain either because of the shape of the toes, the inability to wear shoes or because of the thick calluses that can form because of the prominent toe rubbing on shoes and socks.
Conservative methods include buying shoes with a very roomy toebox (area around the toes) or having the shoes stretched (in our office), having custom shoes made (normally for diabetics), buying shoes with flexible material to avoid putting excessive pressure on the prominent part of the toe, padding the toes with tube foam and sticky felt pads, wearing multiple layers of socks for extra padding, purchasing bracing devices that temporarily straighten the toe, pads to lift the end of the toe off the ground, and pads to flatten/protect the top of the toe. I could go on but you get the idea here.
Many of the pads above can be found at: http://www.ourdoctorstore.com/saltlake/store/index.asp?department_id=52
We can also stretch your shoes at the source of pain as seen below:(image source)
Surgical treatments include remodeling and fusing the joints that have become deformed, transferring tendons and releasing soft tissues that have shortened and tightened around the deformity. To hold the surgeon's work in place, sometimes a pin is introduced through the skin of the very end of the toe and driven through each bone segment to hold them in perfect alignment.
Recovery from surgery usually requires the patient to wear a special shoe to accommodate the pin at the end of the toe or if no pin is used, to protect the incision site. The patient is allowed to walk in a special post-op shoes or boot. If an externally protruding pin is used, the site is carefully maintained clean dry and protected for 6 weeks or so and removed in the office.
Several advances in the last 10 years have introduced the idea of implants for hammertoe correction. Some of my favorites include:
I-Fuse: created by Orthopro. I think this is the future of implants, with a device you can leave behind for greater stability and still have the option of the temporary wire placement without having to choose between the two.
Truthfully, bones have very few nerves supplying their center so removing the long pin if it is placed isn't any worse than a sharp pinch if anything. The pin placement is not always necessary but depends on the severity of the deformity and the preference of the surgeon. Also used are long screws through the length of the toe, wires, staples, plates etc.
The honest truth is that hammertoes are a tricky problem to correct. Even the perfect surgery can result in crooked toes years later. Success rates are fairly high however and depend on the methods of the surgeon. Always feel free to ask for success examples and levels of success that the surgeon has actually experienced. Any surgeon who says that he never sees complications is smoking something illegal. For some individuals, correcting the hammertoe may help avoid wounds and possible amputations later on. For others, the risks of surgery must be weighed against possible chronic pain or failed correction of the toe deformity.
Advances in anesthesia make actual risk to general health for an average individual very small who undergo minor surgery. Any time surgery is more than skin deep, nerves can be injured, blood vessels compromised and infection may set in. I don't mean to frighten you here, truthfully most surgery comes off without a hitch, however complications do happen.
My point is this: Make sure you know the whole story, know your surgeon, and verify in your own mind that the possible outcomes are worth the risk. Always get a second opinion if you still have doubts. If you feel pressured to have elective surgery, you're probably in the wrong office.
As always I invite questions, comments and the occasional criticisms...
Dan Preece, DPM