PT on the Net Research

Hammer Toe


QUESTION:

I have a problem I'm hoping you can help me with. On my right foot, the first and second Proximal, Middle and distal phalanges curl under when the foot goes into dorsiflexion. I am aware that this is a condition known as Hammer toe and/or hallux rigidus. I have had this problem for the past two to three years after fracturing my tib and fib.

I am getting desperate now due to the fact that I am unable to do many of the functional training exercises that I am incorporating into my training programme. In particular, I am only able to squat down about 10 to 15 degrees before my inability to dorsiflex forces my body weight to shift to the left side. The only way I've overcome that as a temporary measure is by using a heel wedge, but I need to be able to do proper squats. It even hinders my walking to a degree, by forcing my tibia and femur into medial rotation. I have also been experiencing lumbar back pain for the past 18+ months.

What I wanted to know is if there is anything besides surgery and stretching that can sort the problem out? I have been trying to stretch it out for a long time, but all I get is ligament pain. I would be most obliged if you could forward any info you might have on improving this condition.

ANSWER:

Traditional non surgical treatments will always consist of stretching the tight muscles. Unfortunately, it sounds like you have not had much success with this approach. Many people don't realize that with hammertoes, both the toe flexors and extensors are short, and several of the smaller intrinsic muscles of the foot are weak. So you don't want to leave out stretching of the toe extensors, specifically the extensor digitorum longus and extensor hallucis longus.

Due to your injury, it is very possible that you have developed a synergistic dominance of your long toe extensors. These muscles often will substitute for a weak anterior tibialis. One initial step toward improvement may be to increase the strength of your anterior tibialis. The key to this of course is dorsi flexion without toe extension to avoid perpetuating the existing compensation.

You are on the right track with the heel wedge, but perhaps for reasons you didn't think about. The heel wedge will keep your center of gravity forward on the feet or possibly even in front of the feet depending on the height of the wedge. This relieves the anterior tibialis and long toe extensors of their need to pull the tibia forward over the foot (origin and insertion are reversed). Therefore, the substitution of the long toe extensors does not occur.

Occurring concurrently with this scenario is an increased activity on the plantar flexors as the body weight is forward on the foot.  This increased plantar flexor activity will decrease the activity of the extensor digitorum longus and extensor hallucis longus.

A suggestion for squats and exercises that evolve or progress to a squatting position is to keep the weight forward of your ankle joint at all times.  This will probably require a decrease in resistance used in order to safely control your forward motion. It will also create an increased forward translation of your knee in the sagital plane as you squat. Forward translation of the knee has been associated with increased shear forces at the knee, so take that into consideration.

Also, if your environment allows for it, try doing your workouts barefoot and on softer surfaces. This may help you improve motion at the metatarsophalangeal (MP) joints. The lack of motion at this joint will be most evident in your gait. By increasing motion at the MP joints, you will decease pressure that is focused on the metatarsal heads and instead distribute the forces across the toes and metatarsal heads. Softer surfaces in bare feet will also provide greater stimulus to the small, intrinsic foot muscles.

Another common physical therapy/orthopedic intervention is to tape the hammertoes into position, anchoring them with the unaffected toes. This is not a permanent solution, but used in conjunction with the modified squat motion, it may help to avoid reinforcing undesirable movements at the foot and toes.

Anthony Carey M.A., CSCS, CES
www.movementbydesign.com