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Understanding The World of Hammertoe Treatments

 

If you have a hammertoe and are seeking professional treatment this article will introduce you to the 4 main categories of hammertoe treatments and which professional specialties are involved in each—including my commentary at the end of this article.

 

 

The four main categories of hammertoe treatment.

 

Medical

 

These treatments are focused on treating underlying diseases and Trauma (see: Causes of Hammertoes) such as diabetes rheumatoid arthritis, stroke, neurological and general orthopedic (e.g.—accidents, spine, hip, knee problems). The medical specialists (primary care Dr., endocrinologists, rheumatologist, physical therapist etc) managing the patient’s illness are vital for your overall health but generally speaking they may not be the best choice for direct treatment of the hammertoe itself.

 

Shoe

 

These treatments center around fitting, modifying, customizing, eliminating, and even fabricating shoes to reduce/eliminate shoe related injury. Podiatrists and Pedorthists (shoe specialists) are good choice specialists for these treatments. In addition devices like insoles and orthotics that fit inside the shoes are attempts to control the biomechanical forces resulting from a body structure anomaly— such as high and low arch feet, uneven leg length, etc. Podiatrists, Pedorthists, Orthotic labs, Orthopedists, and Chiropractors all exist in this treatment space. One should expect however a wide range and sometimes conflicting professional opinions and philosophical approaches when comparing their recommendations.

 

Non-surgical toe/foot

 

These treatments generally focus on relief and management of the symptoms of your hammertoe rather than direct correction of the hammertoe itself. Treatments include corn,callous ulceration trimming, local injections, oral meds for acute pain/inflammation/infection, topical creams/ointments, exercises/stretches, bandaging, custom appliances, strapping and padding the toes. Podiatrists are the obvious choice here although some callous trimming and nail cutting maintenance can be done by Pedicurists.

 

Surgical toe/foot

 

These treatments focus on elimination of symptoms and restoring or improving any lost functions of the toe. Theoretically these treatments can provide the fastest, most satisfying and longest term benefits, of course there are also risks, costs, and conflicting professional viewpoints. Podiatrists and Orthopedic surgeons are the only choices in this treatment space. Furthermore there is narrow subset of Doctors in those groups who actually perform hammertoe surgery on a regular basis.

 

I consider toe surgery treatment so important that I am dedicating the whole next section to presenting this world to you.

 

Approaches to toe surgery

 

Toe surgery theoretically has the most potential of all toe treatments for patient satisfaction and achievement of their goals due to ability to directly physically change the position, shape and length of the toe.

 

To help you understand hammertoe surgery you should understand that one general objective is to restore the position of the abnormal bends in the toe. On most toes there are three joints (areas where two bones are connected by ligaments) which allow movement of the bones by action of the tendons (part of muscles) all covered with a cylinder of skin. There are basically five surgical approaches to solve the abnormal “bend” at one of these joints:

 

Joint fusion

 

Remove both opposing surfaces of the joint bones and then hold them together with some type of implant- metal or nonmetal-and either removable or non-removable.

 

Pros

Joint is eliminated so no motion can ever occur there. Works best when there is some uncontrollable force that is bending the toes—like a post stroke patient where there can be a strong imbalance in muscle strength across that joint.

 

Cons

Toes feeling pencil like and not adapting to shoes well, procedures involve fixation devices that can fail resulting in another surgery to remedy that, costly-some devices cost over $1000— and have to be done in a surgical facility for insurance reimbursement, loss of toe function at that joint, does not work well with toe shortening strategies, and in my opinion tends to be overused.

 

Joint replacement

 

Both sides of the joint bones are removed and replaced with an artificial implanted joint. (like a knee joint replacement idea for the toe joint).

 

Pros

Can help maintain toe length, allows some joint motion.

 

Cons

Expensive, history of failures, not used very much anymore.

 

Joint remodeling

 

Removal of bone on one side of the joint only. The other side is kept intact. This will prevent the joint from fusing together and allows the regeneration of a natural functional joint.

 

Pros

Long history of success, do not have to use a pin, joint reforms allowing motion, cost effective-no implants fees and procedure can be done in office, works well with toe shortening procedures and shoe fit problems.

 

Cons

Can have “bend” recurrences with patients with muscle imbalances, can have problems with maintaining proper alignment post surgically.

 

Joint repositioning via tendon

 

No bone removal here. Just lengthening, shortening, rerouting or just cutting of tendons and ligaments that are holding the joint in the bent position.

 

Pros

Joints remain intact, no bone healing to go through, small incisions reduce scarring.

 

Cons

High rate of recurrence of hammertoe, in my opinion only useful (on its own) in a small percentage of hammertoe cases.

 

Joint repositioning via skin plasty

 

Changing the joint position by lengthening tight skin, shortening excess skin, moving good skin into defects left by removing a corn (skin flap), or joint reposition correction from any joint deviation through a skin plasty.

 

Pros

An absolute requirement for some hammertoes, best for corn lesion removals, can restore wonderful natural looking appearance to toe, superb for hiding/fading scars for cosmetic effects, proper use can eliminate need for pins.

 

Cons

Procedures considered difficult to learn, design and perform with few Podiatrists comfortable in using them, lack of available training and/or literature in these techniques on toes, and in my opinion a vastly underutilized resource.

 

Commentary on toe surgery by Dr. Keyes

 

In my experience 95% of all the hammertoes I see on a daily basis are primarily caused from the interaction of the patient’s toes/foot in the shoes they wear. There is a fairly wide variation is the shape, dimensions, and relative size proportions of peoples’ toes/feet who then have to fit those feet into standardized shoes. For example if you have a narrow foot with long toes naturally then a standard shoe with an appropriate length will probably feel roomy inside allowing your foot to slide around which would then be counteracted by “scrunching” up the toes to compensate for that. In the absence of some body trauma or disease (e.g.- stroke) then the real challenge in toe surgery is to transform the patient’s toes to fit standardized shoes. The opposite would be to have custom shoes made to properly fit such feet—of course that is not really a practical alternative in today’s society.

 

To accomplish the above I have found that utilizing a combination of techniques: Joint remodeling, Joint repositioning by tendon, and Joint repositioning via skin plasty in customizing a surgical plan for each individual patient’s toe gives the best restoration of toe function (see Functions of Normal Toes) , improved shoe fit and comfort, and an overall natural and cosmetic appeal.

 


Larry A Keyes DPMDr. Larry Keyes is a podiatrist in Oak Park, IL. Since 1998, he's been changing his patients' lives after perfecting a safe, simple and zero-downtime solution to correcting hammertoes, the removal of corns and prevention of keloids.

1023 Madison Street, Oak Park, IL 60302
708-771-4300

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