Hammertoe Correction

Why this approach — at MOS

Hammertoe surgery has a reputation for unpredictability — the term "sausage toe" describes the prolonged swelling that can last months after surgery. I address this with patients directly before surgery, so expectations are realistic. Swelling is normal and expected. The toe will look "big" and stiffer than hoped for the first 2–4 months — this is not a sign of a bad result.

For rigid hammertoes requiring arthrodesis, I prefer intramedullary implants over K-wires when bone quality is adequate, because patients don't have to manage a protruding wire through the toe tip for weeks, and the risk of pin tract infection is eliminated. For flexible hammertoes, I use the flexor-to-extensor transfer technique because it corrects the dynamic muscle imbalance driving the deformity, not just the structural deformity itself.

When a patient presents with both a bunion and a hammertoe of the second toe — a very common combination in the Bethesda area — I typically correct both in the same operation, because treating the bunion alone leaves the hammertoe unaddressed and vice versa.

Who is a candidate?

Indications

• Painful hammertoe with corn or callus on the dorsal PIP joint that interferes with shoe wear and daily activity
• Rigid hammertoe that cannot be manually corrected
• Flexible or semi-rigid hammertoe failing 3–6 months of non-surgical care
• Hammertoe causing skin ulceration (especially in diabetic patients)
• Crossover toe (the toe has deviated over or under an adjacent toe) causing functional impairment
• Hammertoe corrected in conjunction with bunion surgery (very common combined procedure)

Contraindications

• Mild, flexible hammertoe with minimal symptoms — accommodative shoe wear is first-line
• Active infection or ulceration not yet debrided and cleared
• Peripheral vascular disease insufficient for wound healing
• Poorly controlled diabetes (optimize glucose control before elective surgery)

Conservative Treatment First

Wide, deep toe-box footwear is the most effective conservative measure — shoes that allow the toes to lie flat without dorsal compression prevent pain during shoe wear. Commercially available gel toe separators, toe crest pads, and metatarsal pads redistribute plantar pressure and reduce friction on the dorsal PIP joint.

Taping and strapping techniques can hold a flexible toe in a corrected position during activity. Orthotics with metatarsal relief can unload the painful plantar forefoot. Surgery is considered only when a well-executed conservative program has failed to provide adequate symptom relief over 3–6 months.

The procedure

What Is Hammertoe Correction?

Hammertoe correction is surgery to straighten a toe that is permanently bent at the middle joint (PIP joint). The procedure releases tight tendons, removes a small portion of bone, and may use a pin or implant to hold the toe straight while it heals. Surgery is reserved for hammertoes that are painful and have not responded to shoe modifications or padding.

A hammertoe is a deformity in which the second, third, fourth, or fifth toe bends at the proximal interphalangeal (PIP) joint, creating a characteristic downward curl. This bent position causes the dorsal (top) surface of the toe to rub against shoe uppers, forming painful corns and calluses. The ball of the foot beneath the metatarsal head is also frequently painful because the deformity shifts pressure forward.

Hammertoes exist on a spectrum. A flexible hammertoe can be manually straightened with finger pressure — the joint still has normal range of motion. A rigid hammertoe is fixed in position — the joint cartilage and soft tissues have contracted and will not allow passive correction. Surgical technique differs based on this distinction.

Most hammertoes are associated with bunion deformity (the crowding big toe pushes the second toe into a bent position) or tight, narrow footwear worn over years. Muscle imbalance between the intrinsic and extrinsic foot muscles also plays a role.

What Happens During Hammertoe Correction?

Surgery is performed at an ambulatory surgery center as an outpatient procedure under ankle block anesthesia.

Flexible Hammertoe — Arthroplasty with Flexor-to-Extensor Transfer: For flexible hammertoes, a tendon transfer is often the preferred technique. The flexor digitorum longus tendon (which pulls the toe down) is released from the toe tip and re-routed to the top of the proximal phalanx, converting its pull from flexion to extension. A small portion of the PIP joint is sometimes removed to allow the toe to sit flat. The toe may be held with a temporary pin through the tip.

Rigid Hammertoe — PIP Joint Arthroplasty or Arthrodesis: For rigid hammertoes, correction requires removing tissue at the PIP joint. A small (1.5–2 cm) dorsal incision is made over the PIP joint. The extensor tendon is split and the joint capsule is opened. Arthroplasty removes the cartilage and a few millimeters of bone from the head of the proximal phalanx, creating space for the toe to straighten. Arthrodesis removes the cartilage from both joint surfaces and holds the toe straight with a pin or intramedullary implant while the bones fuse. Arthrodesis is more reliable for preventing recurrence but results in a permanently straight (non-bending) toe at that joint.

Pin or Implant: A smooth K-wire (Kirschner wire) passed through the toe tip is the classic fixation method, extending out the end of the toe for 4–6 weeks, then removed in the office. Newer intramedullary implants (e.g., titanium or nitinol devices) are entirely internal and do not require removal — these are increasingly used for improved patient comfort.

Concurrent Procedures: Hammertoe correction is frequently combined with bunion surgery on the same foot in a single anesthetic, and sometimes with metatarsal osteotomy (Weil osteotomy) to decompress a subluxed MTP joint.

Recovery timeline

Frequently Asked Questions