Hammertoe is a common toe deformity where one or more of the smaller toes bend downward at the middle joint, creating a hammer-like appearance. This deformity can lead to discomfort, pain, and difficulty wearing shoes. Over time, the condition may cause the development of painful corns and calluses on the top or tip of the toe. When non-surgical treatments such as splints, padding, or shoe modifications fail, surgical correction may be necessary to restore proper alignment and relieve pain.
How Common It Is and Who Gets It? (Epidemiology)
Hammertoe deformity most often affects adults, particularly women, due to long-term use of tight or high-heeled shoes. It is more common in individuals with muscle imbalance, flatfoot deformity, or arthritis. The second toe is most frequently involved, followed by the third and fourth toes. The likelihood of developing hammertoe increases with age, as tendons and ligaments lose flexibility.
Why It Happens – Causes (Etiology and Pathophysiology)
Hammertoe occurs due to an imbalance between the muscles and tendons that control toe movement. When the flexor tendons overpower the extensors, the toe bends downward at the middle joint (the proximal interphalangeal or PIP joint). This can be caused by wearing tight shoes, foot structure abnormalities, trauma, or neurological conditions. Over time, the toe becomes rigid, making it difficult or impossible to straighten without surgery.
How the Body Part Normally Works? (Relevant Anatomy)
The smaller toes contain three bones connected by two joints. The PIP joint allows the toe to bend at the middle. In a normal toe, the tendons on the top and bottom work together to keep the toe straight and flexible. When this balance is disrupted, the PIP joint contracts and becomes fixed, leading to hammertoe deformity.
What You Might Feel – Symptoms (Clinical Presentation)
Common symptoms include a visible bend in the toe, pain while wearing shoes, and irritation from rubbing on the top of the joint. Corns or calluses may form over the knuckle or on the tip of the toe. In advanced cases, the toe becomes rigid, swollen, and inflamed, making walking painful.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is based on a physical examination of the foot. The doctor evaluates toe alignment, flexibility, and associated corns or calluses. X-rays help assess the severity of deformity and check for arthritis, bone spurs, or joint damage. This information guides the decision between non-surgical and surgical treatments.
Classification
Hammertoes are classified as either flexible or rigid. Flexible hammertoes can be straightened manually and may be treated with conservative measures. Rigid hammertoes are fixed in position and usually require surgery. The condition can also be mild, moderate, or severe depending on the angle of deformity and associated pain.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that may resemble hammertoe include mallet toe, claw toe, overlapping toes, and capsulitis of the metatarsophalangeal joint. Proper diagnosis is important to ensure the right treatment approach.
Treatment Options
Non-Surgical Care
Early stages of hammertoe may respond to conservative care. Wearing shoes with wide toe boxes, using toe splints, and adding pads or orthotics can help reduce friction and pressure. Anti-inflammatory medications and stretching exercises may also relieve symptoms. However, these methods do not correct a rigid deformity.
Surgical Care
For fixed or painful hammertoes, surgery is often recommended. The most common procedures include PIP joint resection arthroplasty and fusion (arthrodesis).
- PIP Joint Resection Arthroplasty: The surgeon removes a small portion of bone from the PIP joint to straighten the toe and relieve pressure.
- PIP Joint Fusion: The damaged surfaces of the PIP joint are removed, and the bones are permanently joined together to maintain alignment.
During both procedures, a small incision is made on top of the toe, and the ligaments and tendons are released to allow realignment. A temporary metal pin (K-wire) or internal implant holds the toe straight while it heals.
Recovery and What to Expect After Treatment
After surgery, the foot is wrapped in a soft dressing or placed in a special shoe to protect the toe. Patients may walk on their heel within a few days, though full recovery takes several weeks. The K-wire is typically removed after three to six weeks. Physical therapy or range-of-motion exercises help maintain flexibility and strength.
Possible Risks or Side Effects (Complications)
While complications are uncommon, potential risks include infection, stiffness, numbness, swelling, and recurrence of the deformity. Some patients may experience persistent pain or mild toe shortening after resection arthroplasty.
Long-Term Outlook (Prognosis)
Hammertoe surgery provides excellent results for most patients, with over 90% reporting pain relief and improved toe alignment. The surgery allows patients to wear regular shoes comfortably and resume normal activities. Although recurrence can occur in some cases, especially with severe deformities, most patients remain satisfied with their results.
Out-of-Pocket Costs for Treatment
Medicare
CPT Code 28285 – PIP Joint Resection Arthroplasty or Fusion (Hammertoe Correction, Single Toe): $123.92
Medicare Part B typically covers 80% of the approved cost for this procedure after your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover the remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These supplemental plans coordinate with Medicare to close the coverage gap and lower patient costs.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover any remaining coinsurance or small deductibles, which typically range between $100 and $300, depending on your plan and provider network.
Workers’ Compensation
If your PIP joint arthroplasty or fusion is needed due to a work-related injury or repetitive strain condition, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and postoperative care. You will not have any out-of-pocket costs, as the employer’s insurance carrier pays for all approved treatments directly.
No-Fault Insurance
If your toe deformity or injury requiring PIP joint correction is related to an automobile accident, No-Fault Insurance will typically cover the entire cost of your procedure, including surgery and follow-up care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your insurance policy.
Example
Linda Reynolds suffered from a painful hammertoe deformity and underwent a PIP joint resection arthroplasty (CPT 28285). Her estimated Medicare out-of-pocket cost was $123.92. Because Linda had supplemental insurance through AARP Medigap, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the surgery.
Frequently Asked Questions (FAQ)
Q. What is Hammertoe Surgery?
A. Hammertoe surgery is a procedure used to correct a hammertoe, a condition where one or more smaller toes bend downward at the middle joint, causing pain and difficulty finding comfortable shoes.
Q. How is Hammertoe Surgery performed?
A. During the surgery, a small incision is made over the bent joint, the ligaments and tendons around the toe are released, and the joint is resected to straighten the toe. A K-wire may be inserted to hold the toe in place while it heals.
Q. What is the recovery process after Hammertoe Surgery?
A. After surgery, patients wear a special shoe or boot to protect the toe. Most people can begin walking gently on their heel within a few days, and the K-wire is removed after 3 to 6 weeks.
Q. What are the expected results of Hammertoe Surgery?
A. Approximately 92% of patients experience pain relief, and 84% are satisfied with the final results, reporting improved toe appearance and function. However, risks include infections and the possibility of recurrent deformities.
Q. Are there alternative fixation options besides K-wires?
A. Yes, newer methods include the use of permanent implants like screws or special memory metal devices, which may provide better long-term results, especially for patients with recurring problems.
Q. How long does the Hammertoe Surgery procedure take?
A. The surgery typically takes about 30 minutes to an hour, depending on the severity of the condition and the specific technique used.
Q. Is Hammertoe Surgery a safe procedure?
A. Yes, Hammertoe Surgery is generally safe with a low risk of complications. However, there are some risks, such as infection and misalignment, which can usually be corrected with additional treatment if needed.
Q. Will I need physical therapy after Hammertoe Surgery?
A. Physical therapy is often recommended to help regain toe mobility, strength, and flexibility after surgery, as well as to reduce stiffness and prevent complications.
Q. How long will I be unable to walk normally after Hammertoe Surgery?
A. Most patients can start walking gently with a special shoe within a few days. However, full weight-bearing activity should be avoided for several weeks to ensure proper healing.
Q. Can Hammertoe recur after surgery?
A. While the surgery is successful for most patients, in some cases, the toe may start to bend again (recurrent deformity). This can be treated with additional minor procedures if necessary.
Q. Is Hammertoe Surgery appropriate for everyone?
A. Hammertoe surgery is typically recommended for patients who have persistent pain or difficulty walking due to a hammertoe, especially after conservative treatments like orthotics or physical therapy have failed.
Q. Will my toe look different after Hammertoe Surgery?
A. Yes, the goal of the surgery is to straighten the bent toe, which can significantly improve its appearance, making the toe look more natural and reducing any visible deformities.
Q. Can I drive after Hammertoe Surgery?
A. It is generally advised not to drive for at least 2 to 4 weeks after surgery, particularly if the surgery was on the right foot or if you require a walking boot or crutches.
Q. How much pain can I expect after Hammertoe Surgery?
A. Most patients experience mild to moderate discomfort after surgery, which can be managed with pain medications and elevation. Swelling and bruising are common in the first few days.
Q. Can Hammertoe Surgery be performed on both feet at the same time?
A. In some cases, Hammertoe Surgery can be performed on both feet simultaneously, but it is typically done one foot at a time to ensure proper healing and reduce the risk of complications.
Summary and Takeaway
Hammertoe deformity causes pain, stiffness, and difficulty wearing shoes. When conservative methods fail, surgery offers a reliable and long-lasting correction. Procedures such as PIP joint resection arthroplasty or fusion restore toe alignment, relieve pain, and improve mobility. Most patients achieve excellent results with minimal complications and a short recovery period.
Clinical Insight & Recent Findings
A recent study published in BMJ Open Diabetes Research & Care examined how a simple procedure called flexor tendon tenotomy affects foot pressure in people with diabetic hammertoe deformities.
In this randomized controlled trial of 45 participants, those who received the tenotomy showed a dramatic reduction in plantar pressure beneath the affected toes — from an average of about 205 kPa to 61 kPa — compared to almost no change in the non-surgical group. The procedure also reduced the number of patients at high risk for diabetic foot ulcers.
These findings confirm that relieving tendon tension effectively lowers pressure on the toe tips, providing a mechanical explanation for why this minimally invasive treatment helps heal and prevent ulcers in diabetic feet. (“Study on diabetic hammertoe and pressure reduction – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Hammertoe surgery is performed by an orthopedic foot and ankle surgeon or a podiatric surgeon. The care team includes anesthesiologists, surgical nurses, and physical therapists for postoperative rehabilitation.
When to See a Specialist?
Consult a specialist if you have a painful, stiff toe that rubs against shoes, causes calluses, or interferes with walking despite conservative treatment.
When to Go to the Emergency Room?
Seek emergency care if you experience severe pain, bleeding, infection, or sudden inability to move the toe after surgery.
What Recovery Really Looks Like?
The first few weeks involve rest, elevation, and limited walking in a post-surgical shoe. Stitches are removed within two weeks, and patients gradually return to full activities after six to eight weeks. The toe continues to strengthen and regain flexibility over several months.
What Happens If You Ignore It?
Untreated hammertoe can worsen over time, leading to increased pain, permanent deformity, corns, and difficulty walking. Severe cases can also affect balance and cause additional foot strain.
How to Prevent It?
Wearing properly fitted shoes, avoiding tight heels, and performing toe-stretching exercises can help prevent hammertoes. Managing underlying conditions such as arthritis or flatfoot also reduces the risk.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and protein supports bone healing after surgery. Avoid smoking, as it can delay recovery and increase the risk of complications.
Activity and Lifestyle Modifications
After recovery, patients should continue wearing supportive shoes and avoid high heels or tight footwear. Regular foot exercises help maintain flexibility and prevent recurrence of the deformity.
Dr. Mo Athar
