Effectiveness of Splinting on Hammertoe

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By Karen A. Oscar, BS, MPT, Rachel M. Morris, BS, MPT, Russell M. Woodman, DPT, FSOM, OCS, MCTA

Hammertoe is one of the most common problems presented to foot and ankle surgeons with the patient complaining about pain and the inability to bear weight on the affected foot. It is characterized by an extended metatarsophalangeal joint of five degrees or more, flexed proximal interphalangeal (PIP) joint of five degrees or more, and a hyperextended distal interphalangeal joint. 8 The deformity generally affects the second toe 10 but can also affect the fifth toe.

Figure 2: Week one, hammertoe deformity of the second phalanx.
Figure 2: Week one, hammertoe deformity of the second phalanx.

There are surgical and conservative treatment options available to alleviate pain and restore function associated with the deformity. To date, surgical treatments have shown moderate successes with a relatively high recurrence rate of the deformity. Conservative treatment options, such as splinting, are generally advised when restoring adequate function and alleviating pain can be achieved without surgery or when the patient does not desire or is a poor candidate for surgery.

Upon reviewing the literature, we noted a lack of investigation into the conservative treatment of splinting in treating pain associated with hammertoe. Therefore, we studied the effects of splinting on a 52-year-old woman who reported seven months of pain localized to the dorsal aspect of the interphalangeal joint of the second phalanx and the plantar surface of the second metatarsal head. She also had limited ability to stand or walk without experiencing pain.

After a ten-week, daily treatment regimen of splinting the affected toe, the patient had no pain and no limitations associated with walking or standing. The statistically significant improvement with splinting this patient warrants additional study with larger populations to promote and establish the effects of splinting for hammertoe.

Assessing Risk

Hammertoe is usually an acquired deformity 1 affecting women over the age of 30 9,7 and athletes who complain of pain while running. Identified risk factors for developing hammertoe can include the following: 5,7,8,9,10

•Pes cavus or pes planus, ankle equines, abnormal toe length or position, neuromuscular dysfunction, inflammatory disease, diabetes, trauma, hallux valgus, biomechanical dysfunction, muscle imbalances, improperly fitted shoes and/or hosiery, and higher heeled shoes.

Conservative Hammertoe Treatments

  • Debridement, orthodigita, corticosteroid injections, nonsteroidal anti-inflammatory medication, orthoses, shoe modification, and patient education. 10,7 Callus trimming to manage the symptoms of pain, and exercise to strengthen intrinsic foot muscles. 7,6

Surgical Hammertoe Treatments

  • Arthrodesis, the most commonly used surgical procedure of various types, has a variety of complications that could occur including post-operative metatarsalgia, infection with fixation, numbness, and/or instability of the joint.
  • Resection procedures, which entail either part or all of a phalanx. Complications can include metatarsalgia, recurrent deformity, stiffness, callus formation, and flexion deformity.
  • Soft-tissue immobilization is the least utilized digital surgical procedure. Again, metatarsalgia, recurrent deformity, stiffness, and callus formation have all been complications with this particular method.

These risk factors do not necessarily lead to deformity but can develop secondary to age-related inefficiencies of the sole, despite the presence or absence of risk factors. 9

Pain is not always associated with hammertoe but when it is, the primary location of the pain is at the plantar surface of the metatarsal head when the proximal phalanx is in dorsiflexion and the metatarsal head is in plantarflexion and pushes into the sole of the foot. 7 As the deformity progresses, it will lead to the development of painful calluses under the prominent metatarsal head and over the prominent PIP joints. 5 Patients in the advanced stages of hammertoe may present with sequelae such as bursitis, tendonitis, gait abnormalities, and degenerative joint disease. 10

Diagnosing hammertoe is done by evaluating historical and physical findings as well as interpreting diagnostic procedures, which can include radiograph. 10, 7 If the patient has elected surgical intervention, laboratory tests and additional diagnostic tests including nerve conduction velocity and noninvasive vascular testing will be necessary. 10

Evaluation of Study Participant

The onset of the patient's pain was insidious and had lasted approximately seven months. She reported pain to the dorsal aspect of the second PIP joint and the plantar surface of the second metatarsal head. Her pain increased with activity and would dissipate with non-weight-bearing activity, but she did not report any alterations in sensation.

Figure 3: Proper technique of donning toe-straightener splint.

Previous treatments for her condition included wearing shoe orthotics prescribed by her podiatrist to correct pronation, suspected to be contributing to the hammertoe deformity. The patient also took 800mg of ibuprofen as needed for pain, but over the course of a month, the treatment was unsuccessful in decreasing her level of disability. Surgical intervention was recommended.

To assess the extent of the deformity, we took several measurements, including range of motion measurements, and found the following:

  • Resting calcaneal stance position was five degrees of calcaneal valgus in relaxed stance and was measured in standing and full bilateral weight bearing.
  • Non weight bearing manual muscle tests found 4/5 weakness of PIP flexion and 3/5 weakness of PIP extension, 12 with both movements causing pain. Other lower-extremity muscle tests were considered normal.
  • Range of motion for the toes was measured by two examiners using a standard 150-degree goniometer. 4 Resting range of motion of the PIP joint was 42 degrees, and the passive range of motion was 67 degrees for PIP flexion and -2 degrees for PIP extension.
  • The dorsiflexed PIP joint was measured at the resting height in millimeters while the patient stood in a relaxed stance. The height of the dorsal surface of the PIP joint was 3.5mm from the level standing surface.

From these measurements, we assumed a direct relationship between the height of the PIP joint and irritation of the joint by the toe box of shoes. By decreasing the elevation of the PIP joint, we deduced that there would be a decrease in pain associated with wearing shoes that would correlate to a decrease of deformity.

Based on this conclusion, we chose to forgo surgical intervention in favor of splinting to address the pain associated with the lesser toe deformity.

Treatment Options

The main goal of treating hammertoe is to provide patients with relief from their symptoms. At the onset of the deformity the toe is flexible and can be treated with non-invasive treatments such as splinting and callus trimming. As the deformity persists, it can become more rigid and will no longer respond to conservative treatments, requiring surgical intervention.

It is surprising that although digital surgery is the most common treatment for hammertoe, there is very little data available in determining which procedure would be the most effective. For the case study participant, we chose to treat the symptoms with splinting the digit using a double-toe straightener. We predicted that splinting would reduce the symptom of pain by providing pressure relief to the plantarflexed metatarsal heads and the dorsal PIP joints. 5

Study Results

Following diagnosis and outlining an intervention, the patient began the treatment regimen of wearing the double-toe straightener to her maximum tolerance for a period of ten weeks. For the first week the patient was averaging five hours a day in the splint, and by the second week she was averaging 11 hours a day.

At the conclusion of the study, the patient's standing tolerance increased from one hour to being unrestricted; her walking tolerance increased from 20 minutes to being unlimited. She had returned to her regular walking and exercise programs, and she was no longer limited by pain. These functional gains were accompanied by objective improvements in mobility.

Subtle increases were noted in range-of-motion testing, and resting PIP joint height decreased by 10mm. This improvement was significant in that the PIP joint was no longer irritated by the toe box of her shoes.

As for pain, at the beginning of the study the patient had a Visual Analog Scale (VAS) pain measurement of 79mm before splinting. After ten weeks of splinting, the VAS score was 0mm.

A reduction in VAS score of 13mm has been reported in the literature as being of statistical clinical significance. 13,1

It is interesting to note that at the start of the ninth week, the subject's pain score increased from a trend of 0mm to 13mm on the VAS. The individual indicated that she did not wear the splint for four days because of some irritation she experienced. Once the irritation subsided, she continued to use the splint.

Concurrent to what is stated in the literature, we recommend the patient continue to use the splint for an additional five months. 7

Karen Oscar and Rachel Morris are graduates of Quinnipiac University's master's degree program in physical therapy.
Russell Woodman, PhD, is a research advisor and professor of physical therapy at Quinnipiac University. Kim Norton, a freelance writer based in Mount Laurel, New Jersey, contributed editorial assistance to this article.

References

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  7. Hurwitz S. (1999) Hammertoe in adults: recognition and clinical management. J Musc Med, 16(8): 460-66.

  8. Myerson MS, & Shereff MJ. (1989) The pathological anatomy of claw toe and hammertoes. J Bone Joint Surg. 71-A (1): 45-49.

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  10. Schuberth, JM. Hammertoe syndrome. Foot Ankle 1999; 38(2): (166-78).

  11. Sorto, LA. (1974) Surgical correction of hammertoes. J. Am. Podiatr. Assoc. 64(12): 930-40.

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  13. Todd KH, Funk KG, Funk JP, & Bonacci R. (1996) Clinical significance of reported changes in pain severity. Ann Emerg Med. 27(4): 485-9.