What Is A Hammer Toe?
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A hammertoe, or claw toe, describes a condition where the toe(s) become buckled, contracted, or crooked. The toe could even cross over an adjacent toe, which is called a cross over toe. Any of the toes may be affected, but the second and Fifth toe are most commonly involved.
Symptoms Of Hammer Toes
Patients with hammer toe(s) may develop pain on the top of the toe(s), the tip of the toe, and/or on the ball of the foot. Excessive pressure from shoes may result in the formation of a hardened portion of the skin (corn or callus) on the knuckle and/or ball of the foot. Some people may not recognize that they have a hammertoe, rather they identity the excess skin build-up of a corn. The toe(s) may become irritated, red, warm, and/or swollen. The pain may be dull and mild or severe and sharp. Pain is often made worse by shoes, especially shoes that crowd the toes. While some hammer toes may result in significant pain, others may not be painful at all. Painful toes can prevent you from wearing stylish shoes.
Causes Of Hammer Toes
Hereditary and shoe gear are probably the most likely reasons to develop a hammertoe. Tight pointy shoes may cause hammertoes. High heels also can cause hammertoes. A deformed toe often develops over time, and certain types of feet may be predisposed. Some patients may develop a hammer toe or cross over toe (of the 2nd toe) due to a bunion of the big toe.
When to Seek Hammer Toe Treatment
Common reasons patients seek treatment for toe problems are as follows:
- Toe pain on the knuckle
- Thick toe calluses
- Interference with walking/activities
- Difficulty fitting shoes
- Worsening toe deformity
- Pain at the ball of the foot
- Unsightly appearance
Toe deformities (contractures) come in varying degrees of severity – from slight to severe. They can be present in conjunction with a bunion, and develop onto a severe disfiguring foot deformity. In advanced cases, the toe can dislocate on top of the foot. Depending on your overall health, symptoms, and severity of the hammer toe, the condition may be treated conservatively and/or with surgery.
Non-operative Treatments for Hammer Toes
Non-surgical methods for hammer toes (claw toes) are aimed at decreasing symptoms (i.e., pain and/or calluses) and/or limiting the progression into a larger problem.
Simple treatments patients can do are:
- Wear supportive shoes
- Use an arch support
- Wear shoes with a wide toe box
- Modify activities
- Spot stretch shoes
- Periodic callus care
Non-surgical treatments Dr. Delvadia, DPM may add:
- Anti-inflammatory Medicines: Prescription strength medicines to decrease pain and inflammation.
- Physical Therapy: To strengthen poorly functioning muscles and stretch tight muscles that may be exacerbating the toes. Special ultrasound techniques may reduce inflammation.
- Custom Foot Orthotics: Dr. Delvadia, DPM creates an orthotic with an exact mold of your foot to better align and support the foot to ease current discomfort and prevent future progression.
- Toe Splints or Pads: Specific pads may prevent pressure and physical irritation in shoes. Toe splints and toe spacers physically realign the toes and can lessen pain and halt or stall hammer toe progression.
- Injections: Cortisone injections are strong anti-inflammatory agents to decrease pain, and swelling directly at the toe region. Injections only treat the symptoms, and in some cases used in caution (and sparingly), they can weaken supporting ligaments of the toe(s).
Hammer Toe Surgery (Toe Shortening, or Toe Augmentation)
Toes can be surgically realigned and made straight again. They can even be made shorter. The good news is that toes can be corrected. Hammertoe surgery is often synonymous with “toe shortening”, “toe job” and/or “toe augmentation”. Depending on the severity and length of the toe, there are several methods to surgically correct a hammertoe. In general, the surgery involves removing a portion of the bone at the contracted joint, to realign the toe.
How Are Hammer Toes Surgically Corrected?
The basis for hammer toe surgery most often involves removing a portion of bone within the toe, to reduce the joint contracture. Depending on the direction the toe has deviated, soft tissue procedures may be necessary along with pinning the toe with a surgical wire.
There are generally two methods surgeons use to correct hammer toes – they are joint resection (arthroplasty) or bone mending (fusion), and the location where this is performed on the toe depends on where the toe is buckled. It’s important to recognize that most of the surgical work involved the joints of the toe, not the joint of the ball of the foot. Sometimes a toe relocation procedure is needed when the joint of the ball of the foot is malaligned (subluxed or dislocated).
- Joint resection procedures involve removing part of one of the two small joints of the toe directly underneath where the digit is crooked. The purpose is to make room for the toe to be re-positioned flat or straight. Because hammer toes become rigid or fixed with time, removing the joint becomes the only option when the knuckle is stiff. It’s important to understand that this procedure does not involve the joint of the ball of the foot, rather the small joint of the toe. Medical terminology for this procedure is called a proximal interphalangeal joint arthroplasty or a distal interphalangeal joint arthroplasty, with the latter involving the joint closer to the tip of the toe.
- Bone-mending procedures realign the contracted toe by removing the entire deviated small joints of the toe (again, not at the ball of the foot). This allows for the buckled joint to be positioned flat and the bone ends to mend together. Often surgical hardware (fixation) is necessary to keep the bones steady during healing. Hardware options can involve a buried implant inside the toe or a temporary wire that is removed at a later date. Medical terminology for this procedure is called a proximal interphalangeal joint arthrodesis (fusion), or a distal interphalangeal joint arthrodesis (fusion), with the former being performed in a high majority of cases.
- Toe Relocation procedures are ancillary procedures that are performed in conjunction with one of the two methods listed about (joint resection or joint mending). When the toe is deformed (buckled) at the ball of the foot, then this joint often needs to be re-positioned along with ligament releases/repair to get the toe straight. A temporary surgical rod is needed to hold the toe aligned while the ligaments mend.
Hammer Toe Surgery Recovery
Recovery after hammertoe surgery generally depends on the method of surgery performed. In all cases, healing takes about 6 weeks in healthy people and there is no way to speed up that process. Patients often return to normal activities and shoe gear by 2 weeks to 3 months depending on just how severe the toe deformity was preoperative. Simple toe surgery can recover very quickly, and return to a shoo-in two weeks – especially with the 5th toe (the 2nd toe is trickier as people push-off of this toe). Factors that may prolong healing are age, smoking, poor nutritional status, and some medical problems.
Walking After Hammer Toe Surgery
Walking after hammertoe surgery is strongly dependent on the method (procedure) surgeons choose to correct the toe and the techniques used to stabilize the digit while mending. Also, the ability to mobilize quicker depends on which toe was operated on. In general, the 4th and 5th toe allow for a quicker return to shoes, as these toes are not needed for propulsion. The 2nd toe, however, is the most commonly deformed toe and tends to have more severe problems, requiring more surgical work.
Nearly all of Dr. Delvadia, DPM’s patients are walking immediately after hammertoe surgery in a stiff-soled surgical shoe. Sometimes, patients may have the bunion repaired at the same surgical setting, and that may dictate whether or not walking would be allowed.
Laser Hammer Toe Surgery
Laser surgery is popular for cosmetic procedures, however, for hammer toe surgery it does not offer any advantage to traditional methods. The laser is useful for soft tissues (not bone), and because hammer toe surgery involves bone procedures, it is not effective.
What Anesthesia Is Needed For Hammer Toe Surgery
Hammertoe surgery is performed as outpatient surgery (this means you go home the same day). It may be performed in a hospital, ambulatory surgery center, and even in the doctor’s office (so long as the facility is set up for surgery). The surgery can be performed under a local, regional, spinal or general anesthetic. Local and regional blocks, with monitored anesthesia care, are most commonly performed. This means that the foot will be numbed with an anesthetic while an anesthesiologist provides sedation to relax you.
Is Hardware Implanted Into The Foot With Hammertoe Surgery?
The use of surgical hardware for hammertoe surgery is very common and depends on the severity of the hammertoe and which toe is operated on. The fifth toe rarely requires surgical hardware, while the 2nd toe almost always does. The surgical hardware may involve stainless steel wires, screws, synthetic material, absorbable pins, cadaveric bone, and/or specialty fixation devices.
A temporary stainless steel rod is most commonly used to hold the bones steady. The rod (medically known as a K-wire) will stick out the tip of the toe and removed in the office once healed – 2 -6 weeks later. Removing of the rod is doesn’t elicit pain usually, rather just an uncomfortable feeling. Sometimes a metal fusion device (for bone mending procedures) is buried within the bone and doesn’t need to be removed, though this type of implant is less ideal when toe relocation surgery is necessary.
Surgically embedded hardware within the toe can remain in your foot permanently. Due to the nature of the implant removing the hardware would undo the surgery that was performed, therefore elective removal is not performed. Use of the rod, in contrast, avoid permanent metallic implants within the toe.
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