Hammertoe: Symptoms, Causes & Treatment Options

What Is Hammertoe?

Hammertoe is a deformity where the toe bends abnormally at the middle joint (proximal interphalangeal joint), causing it to curl downward like a hammer. The condition develops when the muscles and tendons that control toe movement become imbalanced, typically due to ill-fitting footwear, toe length abnormalities, or underlying conditions.

Hammertoe is one of the most common lesser toe deformities, affecting millions of people worldwide. The condition gets its name from the characteristic bent shape of the affected toe, which resembles a hammer when viewed from the side. While any toe can develop this condition, the second toe is most frequently affected, particularly in individuals whose second toe is longer than their big toe.

The deformity develops gradually over time as the tendons and muscles that control toe flexion and extension become imbalanced. In a healthy toe, these structures work together to keep the toe straight and flexible. When imbalance occurs—often due to years of wearing tight or poorly-fitted shoes—the middle joint bends and eventually becomes fixed in the bent position. Understanding this progressive nature is crucial because early intervention when the toe is still flexible offers the best outcomes.

Hammertoe is closely related to two other toe deformities: mallet toe and claw toe. While these conditions share similar causes and treatments, they affect different joints. Hammertoe primarily affects the middle joint (proximal interphalangeal joint), causing the middle portion of the toe to bend upward. Mallet toe affects only the joint closest to the toenail (distal interphalangeal joint), causing the tip of the toe to bend downward. Claw toe is the most severe, affecting both joints and causing the toe to curl completely under itself, resembling a claw.

Types of Hammertoe

Medical professionals classify hammertoe into two main types based on the flexibility of the affected joint:

• Flexible hammertoe: In the early stages, the toe can still be straightened manually. The joint remains mobile, and conservative treatments are usually effective. This stage offers the best opportunity for non-surgical management.
• Rigid hammertoe: Over time, the tendons tighten and the joint becomes fixed in the bent position. The toe cannot be straightened manually, and surgical intervention is often necessary to correct the deformity.

The progression from flexible to rigid hammertoe typically occurs over years, though the timeline varies significantly between individuals. Factors that accelerate this progression include continued wearing of ill-fitting footwear, lack of treatment, and underlying conditions that affect muscle and tendon function.

What Are the Symptoms of Hammertoe?

The main symptoms of hammertoe include a visibly bent toe that points downward at the middle joint, pain or discomfort at the top of the bent toe where it rubs against shoes, corns and calluses from friction, difficulty finding comfortable footwear, and limited toe movement as the condition progresses.

Hammertoe symptoms typically develop gradually, often over months or years. In the early stages, you may notice only minor discomfort or a slight bend in the toe. As the condition progresses, symptoms become more pronounced and can significantly affect your daily activities and quality of life. Recognizing these symptoms early allows for more effective conservative treatment.

The hallmark symptom is a visible abnormal bend in the affected toe. The toe appears to buckle at the middle joint, with the tip pointing downward while the middle section rises upward. This creates the characteristic "hammer" appearance that gives the condition its name. Initially, this bend may only be noticeable when walking or standing, but as the condition progresses, it becomes permanent.

Pain is often the symptom that first brings people to seek medical attention. The pain typically occurs at the top of the bent joint, where the raised portion of the toe rubs against the inside of the shoe. This friction not only causes immediate discomfort but also leads to the development of corns—thick, hardened areas of skin that form as a protective response to repeated pressure and friction.

Common Symptoms Include

• Visible toe deformity: The toe bends abnormally at the middle joint, pointing downward
• Pain at the top of the toe: Especially when wearing shoes, due to friction against the shoe's upper
• Corns and calluses: Thick, hardened skin develops on top of the bent joint or on the ball of the foot
• Redness and swelling: Inflammation around the affected joint, particularly after periods of activity
• Difficulty moving the toe: Reduced flexibility that worsens as the condition progresses
• Pain under the ball of the foot: Metatarsalgia, caused by altered weight distribution when walking
• Difficulty finding comfortable shoes: Standard footwear may feel tight or cause pain

Many people also experience pain under the ball of the foot (metatarsalgia). This occurs because the bent toe alters the normal weight distribution during walking. Instead of weight being evenly distributed across the foot, excess pressure falls on the metatarsal heads—the rounded ends of the long bones that connect to the toes. This can cause aching, burning, or sharp pain in the ball of the foot, particularly during walking or standing.

What Causes Hammertoe to Develop?

Hammertoe develops when the muscles and tendons that control toe movement become imbalanced. The most common causes include wearing tight, narrow, or high-heeled shoes; having a second toe longer than the big toe; bunions that crowd adjacent toes; hereditary foot structure; and conditions affecting nerves or muscles like diabetes or arthritis.

Understanding what causes hammertoe is essential for both prevention and effective treatment. The condition results from a complex interplay of mechanical, genetic, and environmental factors. While any of these factors alone may not cause hammertoe, their combination often leads to the progressive muscle and tendon imbalance that characterizes the condition.

The biomechanics of hammertoe development involve an imbalance between the muscles that flex (bend) the toe and those that extend (straighten) it. Normally, these opposing muscle groups work in harmony to keep the toe aligned. When one group becomes stronger or tighter than the other—typically the flexor muscles—the toe begins to curl. Over time, the tendons adapt to this position, shortening on one side and lengthening on the other, eventually fixing the toe in its bent position.

Footwear as the Primary Cause

Ill-fitting footwear is the most significant modifiable risk factor for hammertoe development. Shoes that are too tight, too narrow, or too short force the toes into a bent position. When worn regularly over years, this constant pressure causes the muscles and tendons to adapt, eventually maintaining the bent position even when shoes are removed.

High-heeled shoes deserve special mention as a major contributor to hammertoe. When wearing heels, the foot slides forward, forcing the toes against the front of the shoe. This creates constant pressure on the toes, particularly the second toe, pushing it into a flexed position. Studies have shown that women who regularly wear high heels have significantly higher rates of hammertoe and other toe deformities compared to those who wear flat shoes.

Common Causes and Risk Factors

• Tight or narrow shoes: Compresses toes, forcing them into bent positions
• High heels: Forces toes forward and downward against the shoe
• Toe length: A second toe longer than the big toe (Morton's toe) is particularly prone to hammertoe
• Bunions (hallux valgus): The deviated big toe pushes against and crowds adjacent toes
• Hereditary factors: Foot structure and muscle balance can be inherited
• Age: Risk increases with age due to weakening muscles and ligaments
• Trauma: Previous toe injuries can damage muscles, tendons, or joints
• Arthritis: Joint inflammation and damage alter toe mechanics
• Diabetes: Nerve damage affects muscle control and sensation
• Neuromuscular conditions: Conditions affecting nerves or muscles (stroke, Charcot-Marie-Tooth disease)

The relationship between hammertoe and bunions is particularly important. Bunions cause the big toe to angle toward the second toe, crowding it and pushing it upward. This crowding forces the second toe into a flexed position, eventually leading to hammertoe. For this reason, people with bunions should be especially vigilant about monitoring their other toes for signs of deformity.

Hereditary Factors

Genetics play a significant role in hammertoe development, though typically through inherited foot structure rather than the condition itself. If your parents or grandparents had hammertoe or other foot deformities, you may have inherited certain anatomical features that increase your risk. These include the length and shape of your toes, the structure of your arch, and the inherent balance of your foot muscles. However, having a genetic predisposition doesn't guarantee you'll develop hammertoe—environmental factors, particularly footwear choices, remain crucial.

When Should You See a Doctor for Hammertoe?

See a doctor for hammertoe if you have persistent toe pain that doesn't improve with home care, notice your toe becoming increasingly rigid, develop open sores or signs of infection, have diabetes or circulation problems, or find that the condition significantly affects your daily activities and footwear choices.

While mild hammertoe can often be managed with home care and proper footwear, certain situations warrant professional medical evaluation. Early consultation with a healthcare provider—typically a podiatrist, orthopedic surgeon, or your primary care physician—can help prevent the condition from worsening and may identify treatment options you hadn't considered.

The timing of seeking medical care is important. As emphasized earlier, flexible hammertoes respond much better to conservative treatment than rigid ones. If you notice a toe beginning to bend abnormally, don't wait until it becomes fixed in position. Early evaluation allows for interventions that may halt or slow progression, potentially avoiding the need for surgery later.

Seek Medical Care If You Experience

• Persistent pain: Toe pain that doesn't improve with rest, ice, or over-the-counter pain relievers
• Increasing rigidity: The toe becomes harder to straighten over time
• Open sores or wounds: Any breaks in the skin, especially on the top of the toe or ball of the foot
• Signs of infection: Redness spreading beyond the immediate area, warmth, swelling, or discharge
• Numbness or tingling: Changes in sensation in the toe or foot
• Significant mobility limitation: Difficulty walking or performing daily activities
• Cosmetic concerns: If the appearance of your toe causes significant distress

What Can You Do Yourself to Treat Hammertoe?

Self-care for hammertoe includes wearing shoes with roomy toe boxes, using over-the-counter pads to reduce friction, performing daily toe stretches and strengthening exercises, soaking feet in warm water to soften corns, and using shoe inserts (metatarsal pads or arch supports) to redistribute pressure. These measures work best when the toe is still flexible.

Many people with mild to moderate hammertoe can successfully manage their symptoms and slow disease progression through consistent self-care measures. The key is addressing the underlying causes—particularly footwear—while protecting the affected toe from further irritation and maintaining flexibility through exercise.

The foundation of hammertoe self-care is proper footwear. This single change can make a dramatic difference in symptoms, particularly in the early stages of the condition. Shoes with adequate toe boxes give your toes room to lie flat, reducing the pressure that causes pain and corns. The shoe should be about 1 centimeter (roughly half an inch) longer than your longest toe, with enough height in the toe box to accommodate the bent joint without rubbing.

Footwear Recommendations

Choosing the right shoes is perhaps the most important thing you can do for hammertoe. The ideal shoe should have several key features:

• Roomy toe box: Wide and deep enough to accommodate bent toes without pressure
• Proper length: About 1 cm longer than your longest toe
• Low heel: Heels under 2 inches (5 cm) prevent foot sliding forward
• Adjustable closure: Laces or Velcro allow custom fit throughout the day
• Removable insole: Allows you to replace with custom orthotics if needed
• Rounded toe: Rounded or squared toe shapes provide more room than pointed styles
• Sturdy heel counter: Provides stability and prevents slipping

When shopping for shoes, it's best to shop in the afternoon or evening when your feet are naturally slightly swollen from daily activity. This ensures the shoes will be comfortable throughout the day, not just in the morning. Always try on shoes with the socks or inserts you plan to wear with them.

Padding and Protection

Over-the-counter pads and cushions can significantly reduce friction and pressure on the affected toe. Several options are available at pharmacies and medical supply stores:

• Hammertoe pads: Small, cushioned pads that fit over the bent joint
• Corn pads: Donut-shaped cushions that relieve pressure on corns
• Toe sleeves: Gel-lined fabric tubes that protect the entire toe
• Metatarsal pads: Placed in the shoe to support the ball of the foot and redistribute pressure

Toe Exercises and Stretches

Regular exercises can help maintain toe flexibility, strengthen the muscles that support proper alignment, and may slow the progression of hammertoe. These exercises are most effective when performed daily:

• Toe stretches: Gently use your hand to straighten the affected toe, holding for 10-15 seconds. Repeat 5-10 times.
• Towel scrunches: Place a towel flat on the floor and use your toes to scrunch it toward you. This strengthens the small muscles of the foot.
• Marble pickups: Place marbles on the floor and pick them up one at a time with your toes, placing them in a bowl.
• Toe spreads: Spread your toes as wide as possible, hold for 5 seconds, then relax. Repeat 10 times.
• Toe taps: While seated, lift all toes, then tap them down one at a time, starting with the big toe.

How Is Hammertoe Treated by Doctors?

Doctors treat hammertoe using a staged approach, starting with conservative measures like custom orthotics, padding, physical therapy, and anti-inflammatory medications. If conservative treatment fails or the toe is rigid, surgery may be recommended. Surgical options include tendon release, joint resection, or fusion, with most procedures performed under local anesthesia as outpatient surgery.

Medical treatment for hammertoe follows a step-wise approach, beginning with conservative measures and progressing to surgery only when necessary. The treatment strategy depends on several factors: whether the hammertoe is flexible or rigid, the severity of symptoms, the presence of other foot conditions (like bunions), and the patient's overall health and activity level.

Most healthcare providers—whether primary care physicians, podiatrists, or orthopedic surgeons—will first recommend non-surgical treatments, even for moderate hammertoe. This is because conservative approaches can be highly effective, particularly for flexible hammertoes, and avoid the risks and recovery time associated with surgery.

Conservative (Non-Surgical) Treatments

Professional conservative treatment builds upon the self-care measures described earlier, adding prescription-strength options and professional expertise:

• Custom orthotics: Prescription shoe inserts designed specifically for your foot structure, providing targeted support and pressure redistribution
• Prescription padding: Custom-made pads or splints that fit your toe precisely
• Physical therapy: Targeted exercises and manual techniques to maintain flexibility and strengthen supporting muscles
• Anti-inflammatory medications: NSAIDs (ibuprofen, naproxen) to reduce pain and inflammation
• Corticosteroid injections: Injections into the joint to reduce inflammation, providing temporary but significant relief
• Splinting or taping: Techniques to hold the toe in a corrected position, most effective for flexible hammertoes

When Is Surgery Necessary?

Surgery becomes a consideration when conservative treatments fail to provide adequate relief, when the hammertoe is rigid and causing significant symptoms, or when the condition interferes substantially with daily activities. The decision to proceed with surgery should be made collaboratively between you and your healthcare provider, weighing the potential benefits against the risks and recovery requirements.

Several surgical procedures are available for hammertoe correction, and the choice depends on the specific characteristics of your condition:

• Tendon transfer or lengthening: For flexible hammertoes, the surgeon may release, transfer, or lengthen the tight tendons to restore balance
• Joint resection (arthroplasty): A portion of the bone at the joint is removed to allow the toe to straighten
• Joint fusion (arthrodesis): The joint is permanently fused in a straightened position using pins, screws, or other fixation devices
• Combination procedures: Often, surgeons combine techniques for optimal results, addressing both the hammertoe and any associated conditions like bunions

What to Expect from Surgery

Hammertoe surgery is typically performed as an outpatient procedure under local anesthesia, meaning you can go home the same day. The surgery itself usually takes less than an hour, depending on the complexity of the procedure and whether other corrections are being made simultaneously.

During recovery, the surgeon removes a portion of bone to allow the toe to straighten. In some cases, a temporary pin is placed through the toe to hold it in position during healing. This pin is typically removed in the office after 3-4 weeks. Most patients receive prescription pain medication for the first few days, transitioning to over-the-counter pain relievers as healing progresses.

Recovery milestones typically follow this pattern:

• First 2 weeks: Rest with foot elevated, limited walking, special surgical shoe
• 2-4 weeks: Stitches removed, gradual increase in walking, continued surgical shoe
• 6-8 weeks: Transition to supportive regular shoes, increased activity
• 3-4 months: Full healing, return to normal activities and footwear

How Can You Prevent Hammertoe?

Prevent hammertoe by wearing properly-fitted shoes with roomy toe boxes and low heels, performing regular toe stretches and foot exercises, addressing bunions and other foot conditions early, maintaining a healthy weight, and having regular foot examinations if you have diabetes or circulation problems.

While not all cases of hammertoe can be prevented—particularly those with strong genetic components—many can be avoided or their progression significantly slowed through proactive measures. The key is addressing modifiable risk factors, particularly footwear choices, before the condition develops or while it's still in its flexible stage.

Prevention is especially important for individuals at higher risk: those with family history of toe deformities, people who wear high heels regularly, those with bunions or other foot conditions, and individuals with diabetes or neuromuscular conditions. For these groups, consistent attention to foot health can make a significant difference in long-term outcomes.

Key Prevention Strategies

• Choose shoes carefully: Prioritize fit and comfort over fashion. Ensure adequate toe box width and height.
• Limit high heel use: Reserve high heels for special occasions, keeping daily wear to heels under 2 inches
• Exercise your feet: Regular toe stretches and strengthening exercises maintain muscle balance
• Treat bunions early: Address hallux valgus before it pushes adjacent toes into deformity
• Monitor toe changes: Pay attention to any changes in toe alignment and seek early evaluation
• Maintain healthy weight: Excess weight increases foot stress and pressure
• Get regular foot checks: Especially important if you have diabetes or circulation problems

For children and adolescents, ensuring properly-fitted shoes is crucial. Growing feet need room to develop normally, and shoes that are too tight can contribute to toe deformities that persist into adulthood. Children should have their feet measured regularly, and shoes should be replaced when they begin to fit snugly.

How Does Hammertoe Relate to Other Foot Conditions?

Hammertoe frequently occurs alongside other foot conditions, particularly bunions (hallux valgus), which affects 90% of people with severe hammertoe. Other related conditions include mallet toe, claw toe, metatarsalgia, and plantar fasciitis. These conditions share common causes and often benefit from similar treatment approaches.

Understanding the relationship between hammertoe and other foot conditions is important because they often occur together, share common causes, and may require coordinated treatment. Additionally, addressing one condition may help prevent or improve others.

Bunions (Hallux Valgus)

The relationship between hammertoe and bunions is particularly significant. Bunions cause the big toe to angle toward the second toe, creating a domino effect of crowding that pushes the second toe upward into a hammertoe position. Studies show that up to 90% of patients with severe hammertoe also have some degree of bunion deformity. When both conditions are present, treatment often addresses both simultaneously for optimal outcomes.

Other Related Conditions

• Mallet toe: Similar to hammertoe but affects only the joint nearest the toenail
• Claw toe: Affects multiple joints, causing the toe to curl under completely
• Metatarsalgia: Pain in the ball of the foot, often caused by altered weight distribution from hammertoe
• Morton's neuroma: Nerve thickening between toes, exacerbated by toe deformities
• Plantar fasciitis: Heel pain that may share common risk factors like improper footwear
• Flat feet or high arches: Foot structure abnormalities that increase hammertoe risk