Hammertoe is a deformity in which one or more of the smaller toes bend downward at the middle joint, creating a hammer-like appearance. It occurs when the muscles, tendons, or ligaments that control toe movement become imbalanced. The deformity can cause pain, swelling, and difficulty wearing shoes. When conservative measures such as wider footwear, splints, and padding fail to relieve symptoms, surgery — such as hammertoe arthrodesis — may be recommended.
How Common It Is and Who Gets It? (Epidemiology)
Hammertoe is a common condition among adults, especially women who frequently wear tight or high-heeled shoes. The second toe is most often affected, though multiple toes can be involved. The condition is more prevalent with advancing age, in patients with flat or high-arched feet, and in those with systemic conditions such as rheumatoid arthritis or diabetes.
Why It Happens – Causes (Etiology and Pathophysiology)
The deformity develops from an imbalance between the long toe muscles (flexors and extensors) and the smaller stabilizing muscles (lumbricals and interossei). This imbalance pulls the toe into a flexed position at the middle joint (proximal interphalangeal joint, or PIP joint).
Common contributing factors include:
- Wearing shoes that are too short or narrow
- Chronic pressure from high heels or tight footwear
- Trauma or previous toe injuries
- Neuromuscular conditions causing muscle imbalance
- Structural deformities like hallux valgus (bunion) or cavus foot (high arch).
How the Body Part Normally Works? (Relevant Anatomy)
Each toe has three joints:
- The metatarsophalangeal joint (MTP) connects the toe to the foot.
- The proximal interphalangeal joint (PIP) is the middle joint, most often affected in hammertoe.
- The distal interphalangeal joint (DIP) connects the last segment of the toe.
Tendons controlling these joints include:
- Flexor digitorum longus and brevis (bend the toe)
- Extensor digitorum longus (straightens the toe)
- Lumbricals and interossei (fine-tune balance and alignment)
When these muscles and tendons lose coordination, the PIP joint becomes permanently flexed, leading to the hammer-like shape.
What You Might Feel – Symptoms (Clinical Presentation)
Patients commonly experience:
- A bent toe that may be flexible initially and rigid over time
- Pain when wearing shoes or during walking
- Corns or calluses on the top of the bent joint or toe tip
- Swelling, redness, or irritation over pressure points
- Difficulty finding comfortable shoes
- Limited motion or stiffness in the affected toe.
How Doctors Find the Problem? (Diagnosis and Imaging)
A foot and ankle specialist diagnoses hammertoe through a physical exam and, if necessary, imaging.
- Clinical evaluation: Checks toe flexibility, alignment, and muscle strength.
- X-rays: Weight-bearing radiographs reveal joint alignment, arthritic changes, or bone deformity.
- Additional assessment: May include evaluation for bunions, neuromuscular disorders, or foot mechanics that contribute to the deformity.
Classification
Hammertoes are typically categorized by flexibility and severity:
- Flexible hammertoe: The toe can still be straightened manually; deformity is not fixed.
- Rigid hammertoe: The joint is stiff, and the deformity is permanent.
This classification helps determine whether soft-tissue procedures or bone surgery (arthrodesis or arthroplasty) is most appropriate.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Claw toe deformity
- Mallet toe
- Hallux valgus (bunion)
- Morton’s neuroma
- Capsulitis or metatarsalgia
A detailed exam differentiates hammertoe from these conditions and identifies combined deformities that may need simultaneous correction.
Treatment Options
Non-Surgical Care
In early or flexible stages, conservative management can relieve pain and slow progression:
- Footwear modification: Wear wide, soft-toed shoes with a deep toe box.
- Padding: Use corn or callus pads to protect pressure points.
- Orthotics: Custom insoles redistribute pressure and improve alignment.
- Splints or toe regulators: Help maintain toe position.
- Exercises: Stretching and towel-grabbing exercises strengthen small foot muscles.
Surgical Care
If non-surgical care fails and the deformity is rigid, hammertoe arthrodesis (fusion) is often the preferred treatment.
- The surgeon removes cartilage from the PIP joint to straighten the toe.
- The two bone ends are aligned and held together with a small pin, screw, or implant until fusion occurs.
- Once fused, the joint no longer moves but remains straight and stable, eliminating pain and pressure.
Alternative procedure:
- Hammertoe arthroplasty (joint replacement): Involves removing part of the joint or reshaping the bone to preserve some motion. This may be chosen for milder deformities or in older, low-demand patients.
Recovery and What to Expect After Treatment
- Post-surgery immobilization: A protective shoe or boot is worn for 4–6 weeks.
- Walking: Most patients can walk immediately after surgery using the special shoe, though weight-bearing may be limited.
- Suture removal: Occurs around two weeks post-surgery.
- Full recovery: Usually within 6–8 weeks, with most patients returning to normal activities pain-free.
Mild swelling and stiffness may persist for several months.
Possible Risks or Side Effects (Complications)
- Infection or wound healing problems
- Stiffness or loss of toe flexibility
- Recurrence or residual deformity
- Nerve irritation or numbness
- Hardware irritation requiring removal
- Transfer pain in adjacent toes or metatarsals.
Long-Term Outlook (Prognosis)
When properly indicated, hammertoe arthrodesis provides permanent correction and excellent pain relief. Most patients regain the ability to wear regular shoes comfortably and resume normal activities. The success rate is high, and recurrence is uncommon when alignment is maintained.
Out-of-Pocket Costs for Hammertoe Arthrodesis
Medicare
CPT Code 28285 – Hammertoe Correction (Arthrodesis or Arthroplasty): $123.92
Medicare Part B covers 80% of the approved cost for hammertoe correction once your annual deductible is met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining 20%, which often eliminates any personal expense for Medicare-approved surgeries. These plans work alongside Medicare to fill coverage gaps, ensuring minimal or no out-of-pocket costs.
If you have Secondary Insurance through an Employer-Based Plan, TRICARE, or Veterans Health Administration, it will serve as the secondary payer after Medicare. These plans usually cover any remaining coinsurance or deductible amounts, which typically range from $100 to $300 depending on your specific policy and provider network.
Workers’ Compensation
If your hammertoe deformity is a result of repetitive motion or a work-related foot injury, Workers’ Compensation will pay all related costs, including surgery, rehabilitation, and follow-up visits. You will not have any out-of-pocket expenses, as these payments are made directly by your employer’s insurance carrier.
No-Fault Insurance
If your hammertoe developed or worsened following an automobile accident, No-Fault Insurance will typically cover the full cost of the procedure and recovery. The only possible out-of-pocket expense may be a small deductible or co-payment as stated in your insurance policy.
Example
Patricia Gomez suffered from painful hammertoe deformities that made walking and wearing shoes difficult. She underwent hammertoe correction (CPT 28285) with an estimated Medicare out-of-pocket cost of $123.92. Because Patricia carried supplemental insurance through Blue Cross Blue Shield, her remaining 20% was fully covered, leaving her with no out-of-pocket expenses.
Frequently Asked Questions (FAQ)
Q. What is hammertoe?
A. Hammertoe is a deformity where the toe bends downward at the middle joint, often due to an imbalance in muscles, tendons, or ligaments.
Q. What are the symptoms of hammertoe?
A. Symptoms include pain, swelling, redness, difficulty wearing shoes, and corns or calluses on the affected toe.
Q. What causes hammertoe?
A. Hammertoe can be caused by genetics, improper footwear, trauma, or arthritis.
Q. What is hammertoe arthrodesis?
A. Hammertoe arthrodesis is a surgical procedure to fuse the bones of the toe, straightening it and eliminating the deformity.
Q. When is hammertoe arthrodesis recommended?
A. It is recommended when non-surgical treatments like shoe modifications, splints, or orthotics fail to relieve symptoms.
Q. How is hammertoe arthrodesis performed?
A. The procedure involves removing cartilage from the joint and using a pin or implant to hold the bones in place while they fuse.
Q. What type of anesthesia is used for hammertoe arthrodesis?
A. The surgery is typically done under local anesthesia with sedation or general anesthesia.
Q. How long does the hammertoe arthrodesis procedure take?
A. The surgery usually takes less than an hour.
Q. What is the recovery time after hammertoe arthrodesis?
A. Recovery typically takes several weeks, with most patients returning to regular shoes and activities within 6 to 8 weeks.
Q. Will I need to wear a special shoe after surgery?
A. Yes, a postoperative shoe or boot is worn to protect the toe and allow healing.
Q. When can I start walking after hammertoe arthrodesis?
A. Most patients can walk immediately after surgery in a special shoe, but weight-bearing may be limited based on the surgeon’s instructions.
Q. Are there risks associated with hammertoe arthrodesis?
A. Risks include infection, delayed healing, stiffness, recurrence, and implant-related issues.
Q. Will I need physical therapy after surgery?
A. Physical therapy is sometimes recommended to restore range of motion and strengthen the toe.
Q. Can hammertoe return after surgery?
A. While the surgery is designed to be permanent, recurrence can happen in some cases.
Q. What should I avoid during recovery?
A. Avoid putting pressure on the toe beyond what your surgeon allows, and refrain from high-impact activities until fully healed.
Q. Is hammertoe arthrodesis effective?
A. Yes, the procedure is generally effective in correcting deformity and relieving pain.
Q. What is hammertoe arthrodesis?
A. It is a surgical fusion of the toe joint to permanently straighten and stabilize a deformed toe.
Q. Who is a candidate for this surgery?
A. Patients with rigid, painful hammertoes that have not improved with shoe changes or orthotics.
Q. Can I walk right after surgery?
A. Yes. Most patients walk immediately in a special shoe or boot, though weight-bearing is limited.
Q. Will the toe move after surgery?
A. No. The fused joint will be stiff, but the toe will remain straight and comfortable.
Q. How long before I can wear normal shoes?
A. Most people resume wearing regular shoes after about six to eight weeks.
Q. Can hammertoe come back after surgery?
A. Recurrence is rare but possible if surrounding toes or foot mechanics are not corrected.
Summary and Takeaway
Hammertoe arthrodesis is a reliable surgical option for permanently correcting a rigid hammertoe deformity. By fusing the joint, the toe becomes straight, stable, and pain-free. The procedure offers long-lasting results, particularly for patients with severe deformities or joint damage. Alternatives such as arthroplasty may be suitable for milder cases, but arthrodesis provides the most stable, durable outcome.
Clinical Insight & Recent Findings
A recent study published in BMJ Open Diabetes Research & Care investigated how a simple surgical procedure—flexor tendon tenotomy—affects hammertoe deformities in people with diabetes. Researchers found that the procedure significantly reduced plantar pressure beneath the affected toes, dropping from an average of 205.6 kPa to 61.3 kPa after treatment, compared to no meaningful change in the control group.
By relieving this pressure, tenotomy lowered the risk of recurrent diabetic foot ulcers and helped improve healing without complications. This evidence supports the role of targeted toe surgery, such as hammertoe arthrodesis or tenotomy, in restoring alignment and relieving pain when conservative measures fail.
For patients with more severe deformities or chronic joint damage, arthrodesis remains a stable and long-term solution that straightens the toe and prevents recurrence, often allowing return to activity within six to eight weeks. Both methods—fusion and tendon release—help relieve pain, restore balance, and reduce pressure-related complications. (“Study on diabetic hammertoe surgery – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
The surgery is performed by orthopedic foot and ankle surgeons or podiatric surgeons. The surgical team may include anesthesiologists, nurses, and physical therapists who assist in pre- and postoperative care.
When to See a Specialist?
You should consult a foot and ankle specialist if you have toe deformity, pain, or difficulty wearing shoes that persists despite non-surgical care.
When to Go to the Emergency Room?
Seek immediate care if you develop redness, swelling, drainage, or severe pain after surgery, as these may indicate infection or hardware complications.
What Recovery Really Looks Like?
Expect mild swelling, stiffness, and limited activity during the first six weeks. Physical therapy may be prescribed to strengthen the foot and improve flexibility in adjacent toes. Full recovery is typically achieved within three months.
What Happens If You Ignore It?
Untreated hammertoe deformities can worsen, leading to painful corns, chronic calluses, and difficulty walking or finding suitable shoes. Over time, arthritis and stiffness can develop.
How to Prevent It?
- Wear properly fitting shoes with a wide toe box
- Avoid prolonged high-heel use
- Strengthen intrinsic foot muscles with stretching and toe exercises
- Treat bunions or flat feet early to prevent imbalance.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and protein promotes bone healing after surgery. Adequate hydration and anti-inflammatory nutrients such as omega-3 fatty acids support joint health.
Activity and Lifestyle Modifications
After surgery, limit high-impact activities until cleared by your surgeon. Once healed, wear supportive shoes and continue gentle foot exercises to maintain mobility and prevent recurrence.
Dr. Mo Athar
