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Hammer Toes: Toeing the Line

Updated: Jul 4


Hammer Toes

This article dives into hammer toes, a common but often overlooked foot issue that impacts the biomechanics of our feet. When hammer toes occur, they disrupt the seamless movements our feet perform, causing a noticeable bend in the toes at the proximal interphalangeal joints. The key takeaway is how patients can utilize manual therapy to mitigate pain and improve function, providing a proactive solution to this condition.


Article Index


 

Introduction

Hammer toes, though they may seem harmless at first glance, are a complicated musculoskeletal issue rooted in the delicate interplay of forces produced by the muscles of the toe. This unusual condition is defined by a flexion contracture at the proximal interphalangeal joint, causing the middle part of the affected toe to rise. If the distal joint also flexes, a claw toe deformity can result.


Person Palpating Their Feet

The root cause of hammer toes is often a disruption in the balance between the flexor and extensor muscle groups, which work together to maintain proper toe alignment and function.


The flexor group, including the flexor digitorum longus and brevis, pulls the toes downward. Conversely, the extensor group, which includes the extensor digitorum longus and brevis, lifts the toes. The intrinsic foot muscles, particularly the lumbricals and interossei, play a crucial role in maintaining this dynamic balance.


When the flexor muscles overpower the extensors, this equilibrium is disrupted. The proximal phalanx is pulled downward while the distal phalanx is pushed upward, resulting in the 'hammer' or 'claw' deformity.


Poorly fitting footwear significantly contributes to this muscle imbalance. Shoes that are too narrow, tight, or have high heels can force the toes into a flexed position. Over time, this leads to the shortening and tightening of the flexor muscles and tendons, encouraging the formation of hammer toes.


Additionally, the type of foot arch can influence the development of hammer toes. High arches (pes cavus) place excessive pressure on the ball of the foot, causing instability and potential toe deformity. Flat feet (pes planus), on the other hand, alter foot biomechanics and can induce muscle imbalances.


Understanding the physiological and biomechanical aspects of hammer toes is essential for developing effective treatment strategies. This knowledge allows for a more focused and personalized approach to managing the condition.


 


Hammer Toes Exercise Image

Exercise for Hammer Toes


We present a detailed protocol below that includes specialized exercises and manual treatments specifically designed to relieve hammer toes. These exercises are meticulously crafted to target the key anatomical structures involved in the development and progression of hammer toes. Meanwhile, manual therapy aims to mobilize affected areas, restoring balance within the foot's biomechanics.


Specific Exercises


Pulling Toes Back: Stretch your toes back before getting out of bed. This exercise promotes increased range of motion and stretches the plantar fascia and intrinsic foot muscles, which are often stiff and contracted in hammer toe conditions.


Flexion and Extension: After pulling back your toes, perform flexion and extension exercises to warm up the intrinsic foot muscles and extensor tendons while improving joint mobility. This helps with the functional biomechanics of the toes and relieves rigidity often associated with hammer toes.


Toe Stretch Sit Backs: This exercise stretches the flexor tendons and plantar fascia by creating a stretch under the toes and along the sole of the foot. It helps lengthen the contracted muscles and fascia, reducing the clawing effect seen in hammer toes.


Standing Toe Stretches and Calf Raises: Standing toe stretches increase the flexibility of the foot and calf muscles, crucial for maintaining proper foot biomechanics and preventing hammer toes. Calf raises strengthen the gastrocnemius and soleus muscles, balancing the forces exerted on the foot and toes.


Towel Scrunches: Towel scrunches strengthen the flexor muscles of the foot and the intrinsic muscles, specifically targeting the flexor digitorum longus and brevis muscles involved in the toe-curling movement seen in hammer toes. Strengthening these muscles can alleviate the contracted state associated with this condition.


 


Manual Therapy For Hammer Toes Image

Manual Therapy for Hammer Toes


Manual therapy for hammer toes utilizes various mobilization techniques targeting structures within the foot and lower leg. These techniques include traction and torsion, interdigital massage, and mobilization of the plantar fascia, flexor muscles, and gastrocnemius and soleus muscles. The goal is to reduce tension, increase mobility, and correct biomechanical discrepancies that may cause or sustain hammer toes.


Traction and Torsion: This technique enhances toe joint mobility, alleviating the stiffness commonly associated with hammer toes.


Interdigital Massage: Focused on the spaces between the toes, this massage helps release tension in the interosseous muscles and promotes better toe alignment.


Plantar Fascia and Flexor Muscle Mobilization: This approach targets the underside of the foot to reduce tension and improve flexibility in the plantar fascia and flexor muscles.


Gastrocnemius and Soleus Muscle Manipulation: By addressing these calf muscles, which are linked to the plantar fascia via the Achilles tendon, this technique indirectly improves foot biomechanics and helps prevent the development of hammer toes.


 

Exercise and Treatment Demonstration


Welcome to our video, "Say Goodbye to Hammer Toes: Hammer toes can be a painful and debilitating condition that affects the toes, causing discomfort and difficulty in walking. The condition is characterized by an abnormal bending of the toes at the middle joint, which can lead to corns, calluses, and other foot problems. The cause of hammer toes is often associated with footwear that is too tight, narrow, or pointed, leading to the abnormal positioning of the toes.


 

Treatment Frequency Recommendations


When performing manual therapy for hammer toes, some patients may experience initial relief or improvement within the first few sessions, especially in terms of pain and flexibility. However, structural and functional changes, such as the realignment of the toe, can take longer and may require consistent therapy combined with exercises and possibly orthotic interventions. The exact timeline for results can vary based on the severity of the condition, patient adherence to home exercises, and individual differences in healing. Regular assessments and feedback are essential to gauge progress and adjust the treatment plan as needed.


Initial Treatment Phase:


  • MSR Manual Therapy: 2 sessions per week for two to three weeks.

  • Home Exercises: Daily functional exercise programs as prescribed by the MSR practitioner.


Response Assessment:


  • Evaluate the patient's response to therapy during follow-up appointments, typically after two to three weeks of treatment.


Positive Response:


  • A positive response to manual therapy for the treatment of hammer toes would be a noticeable reduction in pain and discomfort, coupled with improved toe alignment and enhanced functional mobility during walking and other activities.

  • MSR Manual Therapy: Reduce to 1 session per week.

  • Home Exercises: Continue daily routines; adjust as necessary based on professional advice.


Persistent Symptoms:


  • MSR Manual Therapy: Maintain frequency of two weekly sessions, reassessing the treatment approach weekly.

  • Home Exercises: Re-evaluate and modify exercises under professional guidance, ensuring correct technique and adherence.


When performing manual therapy for Hammer Toes, treatment should continue as long as there's an improvement in symptoms and function. If progress is noted and functional goals aren't yet met, ongoing therapy can be beneficial. If there are no noticeable results, only marginal improvements, or if progress plateaus, then treatment should be reconsidered or halted.


You should transition to maintenance care once the patient has achieved consistent symptom relief and optimal functional levels, ensuring that the achieved progress is sustained and potential recurrences are minimized. All decisions should be based on regular assessments and patient feedback.


Maintenance Phase:


  • MSR Manual Therapy: Monthly sessions or as needed.

  • Home Exercises: Daily routines to maintain benefits and prevent symptom recurrence, with periodic reviews by healthcare professionals.


When considering treatment for Hammer Toes using MSR protocols, the primary focus is on achieving optimal results. The treatment plan is tailored, starting with six sessions in the initial phase. Based on the patient's response, sessions may be adjusted. The number of required visits is based on achieving the best possible outcome for the patient.


 


Image of Feet Without Hammer Toes

Conclusion


This article delves into hammer toes, a common but often overlooked foot issue that disrupts the biomechanics of our feet. Hammer toes cause a noticeable bend in the toes at the proximal interphalangeal joints, leading to pain and functional impairment. The key takeaway is the importance of manual therapy and specialized exercises in mitigating pain and improving function. These proactive strategies provide an effective solution to managing this condition.


By understanding the underlying causes and implementing targeted treatments, patients can achieve significant relief and improved foot function. Whether through pulling toes back, performing flexion and extension exercises, or engaging in manual therapy techniques, these interventions aim to restore balance and alleviate the discomfort associated with hammer toes. Consistent treatment and regular assessments ensure the best outcomes, promoting long-term foot health and mobility.


 

References


  1. Abelson, B., Abelson, K., & Mylonas, E. (2018, February). A Practitioner's Guide to Motion Specific Release, Functional, Successful, Easy to Implement Techniques for Musculoskeletal Injuries (1st edition). Rowan Tree Books.

  2. Banta, H. D. (1997). Clinical Examination of the Musculoskeletal System: Assessing Rheumatic Conditions. 2nd ed. Springer. ISBN-13: 978-1850706817.

  3. Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed hammertoe deformity. Foot Ankle Int. 2000;21(2):94-104.

  4. Frowen, P., O'Donnell, M., & Burrow, J. G. (2010). Neale’s Disorders of the Foot. 8th ed. Churchill Livingstone. ISBN-13: 978-0702031717.

  5. Klein EE, Weil L Jr, Weil LS Sr, Knight J. Clinical examination of the foot and ankle. Prim Care. 2014;41(1):53–70.

  6. Klein EE, Weil L Jr, Weil LS Sr, Knight J. Hammertoes: Treatment and Surgical Options. Prim Care. 2014;41(1):53–70.

  7. Nix SE, Vicenzino BT, Collins NJ, Smith MD. Characteristics of foot structure and footwear associated with hallux valgus: a systematic review. Osteoarthritis Cartilage. 2012;20(10):1059–1074.

  8. Parekh, S. G. (2019). Foot and Ankle Examination and Diagnosis. Thieme. ISBN-13: 978-1626236882.

  9. Rome, K., & Brown, C. L. (2004). Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet. Clinical rehabilitation, 18(6), 624-630.

  10. Schrier JC, Palmen LN, Verheyen CC, Jansen J, Koeter S. Hammer toe deformity and the outcome of total knee arthroplasty: a case-control study. Acta Orthop. 2014;85(6):614–618.

  11. Schrier JC, Palmen LN, Verheyen CC, Jansen J, Koeter S. Hammer toe deformity and the outcome of total knee arthroplasty: a case-control study. Acta Orthop. 2014;85(6):614–618.

  12. StatPearls, "Hammertoe." NCBI Bookshelf. Accessed on October 27, 2023.

  13. Wallace, G. F. (1982). Foot Examination and Diagnosis. 2nd ed. Butterworth-Heinemann Ltd. ISBN-13: 978-0723607576.

  14. Yates, B. (2008). Merriman's Assessment of the Lower Limb. 3rd ed. Churchill Livingstone. ISBN-13: 978-0443104683.


 

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DR. BRIAN ABELSON, DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centred care and advancing treatment methods.




 


MSR Instructor Mike Burton Smiling

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