History
A patient with symptomatic hammertoe typically complains of pain over the dorsal aspect of the proximal interphalangeal (PIP) joint of the affected toe. Occasionally, the patient also complains of pain over the plantar area of the metatarsal head, especially if the metatarsophalangeal (MTP) joint is hyperextended, subluxated, or dislocated.
A callus may be present over the dorsal surface of the PIP joint, over the plantar surface of the metatarsal head, or at the tip of the toe (see the image below). In addition, patients with MTP joint instability often complain of pain over the dorsal part of the MTP joint, and they may describe the sensation of a lump in the plantar area of the MTP joint.
Painful dorsal callus over proximal interphalangeal (PIP) joint of second toe, caused by long-standing, fixed hammertoe deformity.
Physical Examination
The physical examination of hammertoe deformity must include the following:
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Neurovascular evaluation, including palpation of pulses
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Sensory examination, with emphasis on protective sensation
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Evaluation of intrinsic muscle bulk
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Assessment of flexibility (is the deformity flexible or rigid?)
The deformity should be assessed while the patient is standing so that its functional significance can be better appreciated. Accompanying deformities, such as hallux valgus, combined hammertoe and rotational deformity, and cavus foot deformity, must be catalogued. Passive correction of the deformity should be attempted because this will help determine which treatment options are appropriate for the patient.
Palpate both the plantar and articular portions of the metatarsal head, because patients with MTP instability have greater tenderness of the articular portion and may require treatment different from that of patients with isolated hammertoe. Pain with dorsal subluxation of the MTP joint implicates MTP instability (see the image below). Palpate the webspace, and compress the forefoot by squeezing the metatarsals together from medial to lateral. These two maneuvers help exclude an interdigital neuroma, which often is confused with MTP instability.
Physical examination maneuver to diagnose metatarsophalangeal (MTP) instability, wherein examiner attempts to translate proximal phalanx dorsally relative to metatarsal head. In most patients, subluxation is possible; therefore, this test is positive only when it causes pain.
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Diagram comparing clinical appearances of lesser-toe deformities.
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Morton foot, wherein second ray (metatarsal and corresponding toe) is longer than first ray.
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Pathomechanics of hammertoe deformity. Elongated plantar plate, caused by either metatarsophalangeal (MTP) synovitis and instability or chronic MTP hyperextension due to toe crowding, results in MTP subluxation or dislocation with compensatory proximal interphalangeal (PIP) flexion.
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Painful dorsal callus over proximal interphalangeal (PIP) joint of second toe, caused by long-standing, fixed hammertoe deformity.
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Physical examination maneuver to diagnose metatarsophalangeal (MTP) instability, wherein examiner attempts to translate proximal phalanx dorsally relative to metatarsal head. In most patients, subluxation is possible; therefore, this test is positive only when it causes pain.
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Hammertoe shield for treatment of flexible hammertoe. Sling over proximal phalanx straightens toe, while shield under metatarsal head provides padding for painful callus that may be present, supports toe plantarly, and anchors sling.
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Severe hammertoe deformity in second toe overlapping great toe with associated hallux valgus deformity.
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Anteroposterior radiograph showing hammertoe deformity in second toe and associated hallux valgus deformity in forefoot.
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Lateral radiograph showing hammertoe deformity.
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Intraoperative fluoroscopic image showing correction of deformities in first and second rays and use of Kirschner wires to stabilize osteotomies.
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Anteroposterior radiograph at 3-month follow-up showing correction of hammertoe and hallux valgus deformities.
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Lateral radiograph at 3-month follow-up showing correction of lesser-toe deformity.
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Clinical photograph showing correction of deformities involving second and great toes.
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"Sausage toe" complication occurring after Girdlestone-Taylor tendon transfer.
