Hammertoe Deformity

Hi, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. And today we'll be talking remotely with Dr. Brett Fink. Dr. Fink is an orthopedic foot and ankle surgeon who practices in Indianappolis. He now currently serves as the President of the Indiana Orthopedic Center. Dr. Fink completed his medical school at the Washington University School of Medicine in St. Louis, Missouri. From there he completed an orthopedic residency in the Portsmouth Naval Hospital. And from there completed two foot and ankle fellowships, one at the University of Miami and the other at Boston University. Thanks for joining us today Dr. Fink.

Dr. Brett Fink: Thank you very much, Randale. It's a pleasure being here.

Dr. Sechrest: Well, today, Dr. Fink, what I thought we would talk about is a fairly common orthopedic foot condition, and that's hammertoes. So, if you would, start out by talking a bit about what causes hammertoes, and how patients know that they have hammertoe deformity.

Dr. Brett Fink: Well, that's a good question about, as far as what causes hammertoes, because I don't think that really anyone knows. Ah, they seem to be a degenerative condition, meaning that as you get older they become more and more common. And it seems to be related to some damage that occurs to some of the small joints in the ball of the foot. These joints to doctors are known as the metatarsal phalangeal joints. When these joints become damaged, a lot of times the posture of the toe will begin to change. It will either, it could overlap other toes, or it could actually raise up and the toe can become curled. As far as what causes it, um, age certainly uh comes into it. The way that you use your foot probably does, but uh, it's difficult to really identify this in the scientific literature. Uh, but it is a very common problem. It's one of the main things that I see in my clinic.

Dr. Sechrest: So, in terms of the symptoms that a patient may experience from a hammertoe, what's the worst set of symptoms that patients typically complain of?

Dr. Brett Fink: Well, for each patient it can be a little bit different. I would say that the first problem is commonly pain in the ball of the foot. People can have unexplained swelling in this area. A lot of times, in my practice, uh, I've got to figure out whether this is this ligament deterioration that I've talked about, or whether it is a um, stress fracture. The physical examination is subtly different. Um, often, the swelling and the pain will go away in the ball of the foot, and will be replaced by the toe deformity. And I think that most people that have had hammertoe know what the toe deformity looks like. The toe begins to look curled. The middle portion of the toe, what we call the proximal interphalangeal joint can start to cock down so that the knuckle on the top of the toe becomes much more prominent. And later on, people can either experience pain on top of that knuckle, when it rises up and hits the shoe, or even at the tip of the toe, when it hits the ground at an unusually acute angle, and becomes uncomfortable to them.

Dr. Sechrest: Now, are hammertoes associated with any other disease processes? Is this something that just comes out of the blue, or do you expect to see other problems that are maybe hammertoes are related to?

Dr. Brett Fink: There are a lot of associated problems that can occur with hammertoes. One of the most common is a bunion deformity. When bunion deformities form, there is not enough pressure on the big toe. And a lot of times the pressure moves over onto the second toe. And, in my belief, this mechanically wears out the toe so that the hammertoe occurs more frequently. Other things that can be associated are things like rheumatoid arthritis, diabetes – it can certainly be part of a diabetic foot, and as people get older, this becomes more and more common.

Dr. Sechrest: Well, we probably should explain, at least briefly, what a bunion is to people who may not be familiar with that term. Can you sort of, maybe give us a description in general, what a bunion is?

Dr. Brett Fink: Sure. Literally, a bunion is a prominence on the inside of the foot. But it usually occurs on the ball of the foot, around the big toe. And basically what happens is that the metatarsal, the long bone in the arch, starts to point towards the midline of the foot. The other part of the toe begins to angle the other way, making the joint very prominent. And what people with bunions generally have is a prominence, or a point at the inside border of the toe, which pushes on the shoe and makes it very uncomfortable.

Dr. Sechrest: Let's move on and talk a little bit about the symptoms that patients may experience that will bring them to a foot and ankle surgeon. What do you think brings patients into your office more commonly?

Dr. Brett Fink: Well, most commonly, it's the unexplained swelling. But also people can come in because of the toe deformity. They just don't know what it is. Some of them think that they've broken their toe, and this, this may prompt them to come in. Because it becomes, because the toe becomes very angled.

Dr. Sechrest: Is there anything that patients should worry about when they see these deformities? Is this something that they definitely need to get in and see an orthopedic foot and ankle specialist right away, or is this something that maybe they can sort of tolerate for awhile before they choose to do anything?

Dr. Brett Fink: Well, I think the important thing is to make sure it's nothing other than a hammertoe. Again, if they had a fractured toe, especially a stress fracture, which can occur without any problem prompting it, a stress fracture can occur without an actual trauma to the foot. And it's important to make sure that it isn't a stress fracture, because if it were a stress fracture, you'd want to protect that in certain circumstances, it may cause the toe not to function very well, and this is something that's prevent, preventable. On the other hand, a hammertoe itself is never really a uh, emergency. Like I said, it's just important to look in and find out whether it's something else.

Dr. Sechrest: Well, lets talk a little bit about diagnosis. When a patient presents to your office with some type of a foot deformity, they may or may not know what it is, how do you begin the process of trying to make the diagnosis of a hammertoe?

Dr. Brett Fink: Oh, well, certainly, the most important thing is to insure that you do a careful physical examination. And I really think that these physical examinations are best done by people that uh, uh are familiar with these problems. If you go to a primary care physician, a lot of times this isn't the thing that they're going see day to day and so they may not know exactly what it is. And a lot of times they're very confused about whether it's a stress fracture versus another diagnosis. As far as the physical examination is concerned, ah, certainly in someone that is very good at examining the foot, a hammertoe deformity is obvious when they see it. It's important to carefully identify where the pain is, because generally the pain occurs in fairly predictable areas. If you have pain that isn't in one of those areas, then that a, that's a problem. So the pain is often directly where these injured ligaments are. And those tend to be right at the bottom of the foot in the ball, located directly over where the bones and joints are in the ball of the foot. Other areas that may become painful later on are areas where there might be a corn, or pressure area developing around a foot deformity. Um, it's also important to identify other medical problems that might be ah, going along with this because they might effect how you go about treating it. In someone that has diabetes uh, because they may lose some of the um, sensation in their foot, the diabetes may, may effect how you uh how you treat the uh hammertoe itself. You may want to protect a hammertoe in a diabetic foot much more carefully than you would in someone that has normal protective sensation.

Dr. Sechrest: And what about imaging? Do you find that x-rays are necessary? Any advanced imaging such as MRI scans or anything like that that you recommend in evaluation of the hammertoe deformity?

Dr. Brett Fink: Well, I think that, I think that x-rays are almost always a, a good idea because, take for instance the case of a diabetic again. You'd want to make sure that that person really wasn't having some kind of diabetic stress fracture, which is very common in people with diabetes. Um, you'd also want to make sure that there is not some type of destructive change going on in the joints that might explain the deformity more ah completely. Um, and you want to make sure that there's not an obvious stress fracture that's been there for a while. Um, as far as further imaging techniques, there are a lot of ah scientific studies that have looked at MRIs or uh bone scans, however, in my opinion, they rarely change what I do. And so I don't, I don't get them as a routine.

Dr. Sechrest: So an MRI scan is not something you're going to order on the first visit, but you, you probably are going to order x-rays on the first visit when you see that patient. Is that accurate?

Dr. Brett Fink: Ya, and and I would say that when you see a , ah a sub-specialist with a foot problem, that they're going to want to get x-rays as a point of routine almost all the time. But in hammertoes I would really say that they're something that I get on a routine basis.

Dr. Sechrest: Okay. Well, let's talk a little bit about treatment. Once you've made the diagnosis of a hammertoe deformity, how are you going to start the discussion with the patient about what is necessary for treatment?

Dr. Brett Fink: Well, my first visit with a patient is always centered around education. I think it's important to give the patient some insight as to what is going on with their foot, Because this is very scary to see that your foot has changed in alignment. I also help the patient to understand that this isn't something that needs emergency surgery, and there aren't usually any problems that can be made worse by observing this for a while. And I find that observing it is really the initial treatment. Um, it's also important to kind of give them an idea of why this has happened. A lot of people blame themselves for these deformities. They blame their high-heeled shoes, and lets face it, every woman has worn high-heeled shoes in the past, and so if high-heeled shoes were the blame for every hammertoe, then everyone would have hammertoes, and everyone doesn't. So it is more or less a combination probably of their genetics and the activities that they've done. Um, after that, we talk about the problem, and really the treatment is geared towards the problem itself. If the problem is really swelling and tenderness, then we discuss a certain shoe wear restriction that they can do that might help take some of the pressure off this. I have found rocker-soled shoes, a while they are kind of not as popular as they once were, are very helpful in decreasing ah forefoot stress. And so I send them out to look at rocker-soled shoes to see if these might help. Occasionally, I will do a steroid injection. There is some controversy about steroid injections, however. Steroid injections are, um, can potentially decrease the metabolism of some of the cells that are trying to repair the areas around these tears. So some people have suggested that steroid injections might actually make a hammertoe deformity ah develop in someone who doesn't otherwise have it. Um, my own feeling ah, is that until there are definite studies that say that steroid injections are a bad idea, ah, I continue to do them. I have not found in my own personal experience that I often see a worsening of the ster, of the hammertoe deformity after a steroid injection. I believe that they are safe, if they've, if they're done in a reasonable manor – meaning, one or two steroid injections, not six or seven or eight or ten. Um, beyond that, and that's usually where we go with the first ah, ah evaluation. Um, I also often start people on stretching exercises. I think that insuring that the Achilles Tendon is flexible enough is important in reducing forefoot overload.

Dr. Sechrest: Now, we, we talked a lot about sort of controlling the symptoms of the hammertoe deformity, is there any way short of surgery, to actually improve that deformity? And what I'm talking about is the looks of the toe, or the way that the toe behaves? Anything you've found that's useful ah, to to impact that rather than surgery?

Dr. Brett Fink: Well, as someone who has suffered from a hammertoe deformity myself, if there is a way, it's not listed in the literature and I haven't found it. I tried several methods when my hammertoe was developing on my right foot, of taping the hammertoe into position, of wearing various braces, and nothing has seemed to help. And if you look back at the underlying problem, this degenerative tear, it's hard to believe that positioning the toe is going to particularly allow that weakened ligament to regain strength. And so, I'd have to say unfortunately, once it's developed, the horse is out of the barn. The hammertoe is going to do more or less whatever, whatever it's destined to do. And there's not much you can do about it.

Dr. Sechrest: Now what about physical therapy? Do you use physical therapists to help people with the Achilles stretching and perhaps some of the symptomatic relief? Or do you feel that most patients can be taught to do this on their own?

Dr. Brett Fink: I usually have my patients, I have some materials that I give the patients to kind of start them on an initial stretching program. Ah, I don't think that therapy is necessary for something so simple as this. However, um, in my own clinic and this is ah, there is completely no scientific evidence about this, I feel that strengthening the intrinsic muscles is an important part of recovering from a hammertoe and preventing problems like hammertoes in the future. So often, I will send patients to be taught a home exercise program that includes some intrinsic exercises. Some exercises that focus on the small muscles of the foot – and these are a little bit more complicated and I do feel that the help of a physical therapist is often very helpful in these.

Dr. Sechrest: Well, lets, lets talk a little bit about surgery. And, and surgery for the hammertoe. You mentioned in diabetics you like to sort of stay away from surgery if at all possible, be very careful with with that population. When you're sitting down to have a discussion with most patients about when it's time to consider surgery, what's going to drive you to start that discussion?

Dr. Brett Fink: Well, most of the time it's my patients that drive me to, to these discussions. My own bent on hammertoe surgery is to be as non-operative as you possibly can. Because I find that ah with the hammertoes surgeries that are available, and the costs and the trade-offs that you make during surgery, that often unless the problem is significant, and severe, that they are not helpful with, they are not ah, particularly happy with the results after hammertoe surgery. Um, so, I generally, again, discuss on the initial visit a, my own feelings about hammertoes, the fact that a lot of times they do go away by themselves, that the pain goes away, but the deformity persists. Um, and if they are able to live with the deformity, and again, most of these, a lot of these patients are at least middle aged, if not elderly, um, a lot of times they've found that there are a lot of problems that they more of less have to deal with, just as a matter of life. Um, so, um, in those patients I encourage them to live with the problem. If it is really not something that they can handle, if they have difficulty finding shoe wear that fits them properly, um, after a good attempt, or they have persistent pain after months of non-operative treatment, then I think it's reasonable to consider this. But, when I'm discussing surgery with them, I emphasize the fact that the toe really doesn't work like normal after a hammertoe surgery. It's stiffer, sometimes the position isn't exactly where they want it. And so, again, unless there's something specific about the hammertoe that they just don't like, we don't rush off into surgery.

Dr. Sechrest: Well, I'm curious, you'd mentioned that that a lot of patients are not satisfied after what you would consider a successful hammertoe surgery. What is their dissatisfaction? What does that stem from?

Dr. Brett Fink: Well, I think that, that people like to have their toes function normally. And unfortunately after a hammertoe deformity, the toes never regain the flexibility that they have. Um, you never, you never regain ah quite the motion that you'd like. Sometimes the incisions themselves cause some numbness on the top of the toes, and people don't like that feeling of numbness. But, even though I myself am very careful when I'm doing these surgeries, to insure that I don't interrupt any major nerves, the nerves, as they get out into the toes are really the size of hairs, and it is very difficult to keep from damaging some of them. And so a little numbness on the top of the toe is something that a lot of people don't like. The recovery after the hammertoe surgery is often prolonged. There is often a great deal of swelling that can go on for 4-6 months, at times, even longer.

Dr. Sechrest: Can you describe for patients that are watching this, in general, how hammertoe surgery is performed?

Dr. Brett Fink: It depends on several aspects of the patient um, that probably a doctor is only going to be able to decide. But, in general, we approach every joint of a hammertoe deformity individually. Um, in my own practice, ah I usually repair the ligament that has been torn on the bottom of the foot to regain the posture of the joint at the ball of the foot, called the metacarpal phalangeal – or metatarsal phalangeal joint. Um, and often this repair is through tissue that's not the best, and so we often have to steal other tendons that are in the area in order to reinforce this. Um, usually this involves pinning the joint for a period of time. And sometimes we have to shorten the metatarsal in order to um decrease the prominence of that bone. Then we a approach the other joints in the foot, the proximal inter phalangeal joint, or the PIP joint, which is the first joint in the toe itself. And a lot of times we have to release the ligaments, or straighten it, or use some kind of ligament transfer technique in order to get the toe straight. And often after these techniques the toe is very stiff.

Dr. Sechrest: So this is a very complex surgery you're describing. This is not simply a a small incision with a release or something of that nature. This is a very uh, complex ah, involved surgical procedure as you're describing it. Is that accurate?

Dr. Brett Fink: I believe that it is. And unfortunately, you would like to have all your surgeries to be complete repairs. To take a gamma structure and fix that and not have to interfere with anything else. Hammertoe surgery unfortunately is not like that.

Dr. Sechrest: Well, lets talk a little bit about complications. You know, it seems like that clearly one of the complications is the stiffness that you have have already described as well as the, maybe some deformity that still remains. Any other complications that you worry about as an orthopedics surgeon that might effect the outcome of this type of surgery?

Dr. Brett Fink: Oh, I think there are a number of complications. Certainly there's the complications of anesthesia, which you've always got to think of. Because most of these surgeries can be done under a local anesthesia, but in general, I think that most practitioners use a general anesthetic, or an anesthetic that puts you to sleep. And there are the complications of that, which you know, in rare circumstances can even mean death. But, the complications that are more specific to a hammertoe are problems with the blood supply to the toe. When you straighten out a toe that has been bent for a while, a lot of times the vessels will spasm and the toe um can lose its blood supply. And in certain circumstances people have lost their toes after hammertoe surgery. Um, the ones that effect the patient satisfaction most are probably residual deformity. And unfortunately after repairing these ligaments, or doing whatever your doctor has, decides what's best, there can be some residual deformities. A lot of times if the hammertoe crosses over the big toe – which is a very common deformity, the toe, even after successful surgery, will tend to lean towards that side. And people can find that very troublesome. In addition, it can lift away from the ground so that the toe doesn't touch the ground quite like you'd want it to. Um, numbness, as we talked about before. Wound problems with the skin on the top of the foot, especially in an elderly patient, the skin can be very thin. Ah, and as you're moving, and retracting, and repairing things, it can damage it. And I have seen people that have lost some of the skin on the top of their toes. Now usually this is, this requires only dressing changes, but it can be psychologically troubling to a patient to have a wound on the top of their foot after what they thought was an elective surgery.

Dr. Sechrest: Well, I think this has been a wonderful discussion that is pretty comprehensively discussed the whole concept of hammertoe and the potential diagnosis and treatment options as well. Do you have any advice for patients that maybe trying to make these decisions, that are watching today, that you learned both through your practice as well as your experience with hammertoe yourself? Anything that you would really want the patients to know if they're watching this?

Dr. Brett Fink: Well, I, I think the most important thing to understand is that a lot of times the pain will resolve on its own. One study that looked at this showed that 60% of people end up with a deformity, but the pain goes away. And in people like that, I think that its a good idea to wait and watch and not get too upset and worried about what might happen. Unfortunately foot deformities that uh, do not interfere with shoe wear are almost a way of life, and just a natural part of the aging process. And if you do decide to go ahead with foot surgery, um, discuss with your doctor and find out very clearly what the expected function of your toe is after the procedure. A lot of times, as you mentioned before, people think, you know, it's just a hammertoe surgery. But people can be, can have an idea of what they think the toe is going to be like that may not reflect what their doctor expects it to be like. And so, a clear and concrete discussion of what is expected after the surgery I think is very important. Um, ah, beyond that, um, just try to use proper shoe wear. Try to find things, shoes that don't press on the toe. And a lot of times people can tolerate this for the rest of their life.

Dr. Sechrest: Well, I think that's excellent advice, and I want to thank you for sharing this with us today, and with the patients who are watching. So, thank you very much and I look forward to future discussions on different orthopedic foot and ankle problems in the future. Thank you.

Dr. Brett Fink: Thank you very much Randale.