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Toeing the Line: A Deep Dive into Hammer Toes

Updated: Dec 5, 2023


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.


The underpinning cause is a disruption in the balance between the flexor and extensor muscle groups. These groups work together to ensure proper toe alignment and function.


The flexor group, comprising the flexor digitorum longus and brevis, pulls the toes downward. In contrast, the extensor group lifts the toes, including the extensor digitorum longus and brevis. The intrinsic foot muscles, especially the lumbricals and interossei, are crucial in maintaining this dynamic balance.


When the flexor muscles become too strong for the extensors, the equilibrium is disrupted, pulling the proximal phalanx downward while pushing the distal phalanx upward, which results in the 'hammer' or 'claw' deformity.


Poorly fitting footwear plays a significant role in creating this muscle imbalance. Shoes that are too narrow, tight, or have high heels can force the toes into a flexed position, leading to shortening and tightening of the flexor muscles and tendons over time, and thereby encouraging the formation of hammer toes.


Moreover, the type of foot arch can contribute to the development of hammer toes. High arches (pes cavus) can place excessive pressure on the ball of the foot, causing instability and potential toe deformity. On the other hand, flat feet (pes planus) can change the foot's biomechanics and induce muscle imbalances.


Gaining a deep understanding of hammer toe's physiological and biomechanical aspects provides the foundation for effective treatment strategies. It enables a more focused and personalized approach to managing this condition.


 


Exercise for Hammer Toes


We present a detailed protocol below that features specialized exercises and manual treatments purposely developed to focus on and provide relief from this condition. These exercises have been methodically crafted to work on the principal anatomical structures that play a role in the evolution and advancement of hammer toes. Concurrently, manual therapy focuses on mobilizing impacted areas to re-establish balance within the foot's biomechanics.


Specific Exercises


Pulling Toes Back: This exercise involves stretching the toes back before getting out of bed. By manually extending the toe joints, we encourage an increased range of motion and facilitate stretching of the plantar fascia and intrinsic foot muscles, which are often stiff and contracted in hammer toe conditions.


Flexion and Extension: The flexion and extension exercise, performed following the pulling back of the toes, aims at warming up the intrinsic foot muscles and extensor tendons while improving joint mobility. This exercise helps with the functional biomechanics of the toes and aids in the relief of rigidity often associated with hammer toes.


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


Standing Toe Stretches and Calf Raises: The standing toe stretches aim at increasing the flexibility of the foot and calf muscles, which are vital for maintaining proper foot biomechanics and preventing conditions such as hammer toes. Calf raises, on the other hand, are excellent for strengthening the gastrocnemius and soleus muscles, helping to balance forces exerted on the foot and toes.


Towel Scrunches: Towel scrunches serve to strengthen the flexor muscles of the foot and the intrinsic muscles, specifically targeting the flexor digitorum longus and brevis muscles that are instrumental in the toe-curling movement seen in hammer toes. By strengthening these muscles, we may alleviate this condition's contracted state.


 


Manual Therapy for Hammer Toes


Manual therapy for hammer toes employs various mobilization techniques targeting diverse structures within the foot and lower leg. These techniques include traction and torsion, interdigital massage, and mobilizing the plantar fascia, flexor muscles, and the gastrocnemius and soleus muscles. This therapeutic intervention aims to lessen tension, augment mobility, and rectify any potential biomechanical discrepancies that may instigate or prolong the existence of hammer toes.


The application of traction and torsion enhances the mobility of toe joints, alleviating the stiffness commonly associated with hammer toes. The interdigital massage concentrates on the spaces intercalating the toes, assisting in releasing interosseous muscle tension and fostering improved toe alignment.


The manual mobilization strategy focusing on the plantar fascia and flexor muscles on the foot's underside intends to mitigate tension and enhance the flexibility of these structures. The gastrocnemius and soleus muscles found in the calf are also manipulated since they can indirectly impact the foot's biomechanics and contribute to hammer toe development, given their linkage to the plantar fascia via the Achilles tendon.


 

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.


 


Conclusion


Hammer toe often begins mildly and can initially be managed with manual therapy and exercise to improve foot function and ease discomfort. As it progresses, it may become rigid, necessitating a change in treatment approach. Although surgery is an option, it's considered a last resort, only explored when conservative measures like manual therapy, exercise, and careful footwear choices haven’t provided sufficient relief.


Notably, hammer toe surgeries constitute 48% of all forefoot surgeries, underscoring the importance of early intervention to potentially avoid surgical interventions. The decision for surgery should be a collaborative choice between the patient and healthcare provider, based on individual symptoms, deformity degree, and response to nonsurgical treatments.


 

DR. BRIAN ABELSON DC. - The Author


Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.

 


Revolutionize Your Practice with Motion Specific Release (MSR)!


MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.


Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.


Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.


With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!

 

References


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  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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