Hammer Toes

A toe that sits bent and no longer lies flat. A corn on the top of it where it meets the shoe, or on the tip where it presses into the sole. A callus under the ball of the foot behind it.

Which joint has bent

The three names describe the same process at different joints, and they overlap:

• Hammer toe — bent at the middle joint of the toe, so the toe humps upward. The most common.
• Mallet toe — bent at the joint nearest the nail, so the tip curls down and the pressure lands on the end of the toe.
• Claw toe — bent at both, and pulled upward at the base as well. Often affects several toes, and is more commonly linked to a neurological cause.

The second toe is affected most often, usually because a bunion has pushed the big toe across into it.

Flexible or fixed, and why it is the important question

Early on, the toe is flexible: it stays bent when you stand but you can straighten it with your fingers. This is the stage where treatment has the most to work with — the joint is not yet stuck, and keeping it moving, offloading it and changing the pressure can hold things where they are.

Left long enough, the joint capsule and the tendons tighten and the toe becomes fixed. It no longer straightens, and no amount of padding, splinting or footwear will make it. Everything at that point is about managing pressure and comfort rather than position, and correcting it means surgery.

The transition is gradual and usually painless, which is why so many people arrive when it has already happened.

What causes it

• Muscle imbalance. The commonest driver: the long tendons that bend the toe overpower the small muscles that keep it straight, and the toe buckles.
• A bunion, crowding the toe beside it.
• Toe length. A second toe longer than the big toe has to bend to fit.
• Footwear that is short or shallow, held over years.
• A high-arched foot, which loads the toes differently.
• Neurological conditions — diabetes with neuropathy, Charcot-Marie-Tooth and others — which change how the small muscles of the foot work. Claw toes developing across several toes at once warrant this being considered.
• Rheumatoid arthritis and other inflammatory joint disease.

Treatment

While the toe is flexible: keeping it moving with toe mobility and intrinsic foot strengthening, silicone splints or crest pads to hold a better position and take the pressure off the tip, and footwear with a deep, roomy toe box. That last one does more work than anything else on the list.

Whatever the stage, the pressure has to be managed. That means reducing the corn or callus that has formed, and then changing what is causing it — padding, a silicone device made to the toe, or an orthotic where the forefoot loading behind the toe is part of the picture.

Where the toe is fixed, painful, and not manageable with footwear and offloading, your podiatrist will discuss referral for a surgical opinion.

⚠ If you have diabetes or reduced sensation, a hammer toe is a pressure point on a foot that cannot feel pressure. Corns on the top and tip of a clawed toe are among the most common sites for a diabetic foot ulcer. Have it assessed rather than padded at home — see diabetic foot care.