The primary cause of hammertoes is a shifting of the body so that the weight-bearing area of the foot transitions from the heel to the ball.
In normal standing posture, 70 percent of weight-bearing pressure should be on the heel and 30 percent on the ball of the foot, but when that weight-bearing pressure shifts anteriorly, the toes buckle and grip the ground to support the forward shifting of weight.
In order to form hammertoes there are two postural distortions that must occur: one is projection of the pelvis anterior to the coronal plane, and the second is projection of the knee anterior to the ankle. A good barometer as to how severe the hammertoes will become is how far the knee moves in front of the ankle.
There are other factors that will increase the likelihood of the formation of hammertoes, such as a forward-head posture or increased pelvic flexion (anteversion). Keep in mind that in some cases of increased lordotic posture, the pelvis is flexed forward but the knee goes behind the ankle, so hammertoes do not form. Remember, it is necessary for the knee to move in front of the ankle for hammertoes to develop.
It’s important to identify if there is anteversion of the pelvis or forward-head posture, or both, in addition to projection. If all three distortions exist, then a very distorted foot will result, including the presence of bunions. Footwear may also play a role in developing hammertoes. High heels tend to project the body forward and increase the pelvic angle, which can result in the body moving anterior of the coronal plane.
It has been reported that having a second toe longer than a first, called a Morton’s toe, will contribute to hammertoe. However, even if the second toe is longer than the big toe, there must still be projection of the knee and pelvis anterior to the ankle.
With a Morton’s toe, if there is projection then the second toe will be the first toe that hammers, as it will actually bear more weight than the big toe. On its own, the second toe being longer is not the cause of hammertoe. The determining factor, as stated above, is the knee moving in front of the ankle.
4 Steps to the Hammertoe Posture
In order to experience the postural factors comprising hammertoes, try this exercise:
1. Rotate your pelvis forward so that your knees are locked back and your back is swayed.
2. Project your pelvis forward in space.
3. Thrust your head forward.
4. Feel what your toes are doing.
If you have performed this exercise correctly, you should feel your toes desperately gripping the floor to keep yourself from falling forward. This is the normal posture for people with hammertoes. Shifting weight back onto their heels will be foreign to them, and they will feel unstable at first.
Traditional Treatment
Hammertoe surgery is marginally effective. When screws are put into the toe with surgery, oftentimes the hammertoes will be gone, but the pain remains. Physically forcing the feet to become straight will in itself move the body back on the coronal plane to a small extent; however, if structural fixations exist, surgery will have a very limited effect on pain in the feet because the problem still remains of the body moving anterior of the coronal plane. Additionally, surgery will not address any accompanying plantar fasciitis.
Non-surgical solutions, such as tape or hammertoe slings, are not typically very effective because people are not likely to stay with them very long. These treatments are cumbersome and simply do not work very well. Instead of slings, foot orthotics can produce quite a bit of relief, since oftentimes when the body is moved anterior the arches will also collapse. Use of an orthotic will help to shift the weight back onto the calcaneus away from the toes.
Through massage therapy, the performance of any orthotic can be improved by putting the person back on the coronal plane.
Treatment Strategies
Before a therapist can begin to address hammertoes, it is important to know if the condition is flexible or fixed.
The success rate for treating flexible hammertoes is very high, as long as there are no arthritic fixations in the neck or the low back. The body will respond to restoring the weight-bearing function on the calcaneus, which is what it’s made for, not on the ball of the foot.
Success with treatment of fixed hammertoes depends on how much damage is done to the joints in the fixed position. If there is capsulitus, deterioration of the articular cartilage, or excessive arthritis, treatment may not repair the joint.
Once the client’s condition is determined, a treatment plan can be designed. Remember, the key to successfully treating hammertoes is to get the patient back on the coronal plane.
There will be five principal areas to focus on:
• The anteriorly projected pelvis
• The anteriorly projected head
• The anteriorly flexed pelvis
• The dorsiflexed ankle
• The foot
Projection of the pelvis is caused by muscular tension in the hamstring, gluteal or low-back muscles—or all three. If there’s pelvis flexion, then the quadriceps is primary along with the adductor muscles, but there is usually a combination of flexion and projection.
Projection is the most important postural distortion to look at because the movement of the body along the horizontal plane is what moves the knee in front of the ankle. It is important to release the hamstring, gluteal and low-back (erector spinae, quadratus lumborum and multifidi) muscles in order to allow the pelvis to migrate posteriorly.
To effectively relieve a forward-head posture, there are two key components to consider. The first is the posterior cervical muscles involved in a forward-head posture, including the posterior suboccipitals, upper trapezius and splenii muscles, which work together to extend the upper cervical spine.
The second is the anterior cervical muscles, including the scalenes, SCM muscles, and lower fibers of the longus colli, which all work together to flex the lower portion of the cervical spine.
To determine if a client has an anteriorly flexed pelvis, the first step is to measure the pelvic angle using the ASIS/PSIS relationship, then see if it is greater than 0 to 5 degrees in a male, or more than 10 degrees in a female. If this is the case, then the next step is to treat the rectus femoris, adductors, tensor fascia latae, quadratus lumborum, erector spinae and obliques.
In relieving the dorsiflexion of the ankle, the anterior compartment of the foot, made up of the tibialis anterior, extensor digitorum longus and extensor hallicis longus, will need to be treated effectively. The flexor digitorum longus will needed to be addressed in the posterior compartment, as it is involved in the flexing of the toes.
The muscles of the foot are also very much involved, mainly the flexor digitorum brevis and the extensor digitorum brevis. The lumbricales are also important to treat, since they participate in both extension and flexion of the toes. Loosening the metatarsal joint capsule using circumduction around the joint 360 degrees will allow the toes to be more flexible when the client stands up.
Prevention Strategy
The best way to prevent the development of hammertoes is to have a good therapist analyze body position on the midsagital, coronal and horizontal planes, and then manipulate the soft tissues to maintain proper posture.
It is also of paramount importance that the therapist educates the client as to what the midsagital, coronal and horizontal planes are, so that he has some understanding and a kinesthetic feeling of what being upright feels like, in order to avoid going back to the more familiar feeling of distortion.
Instruction from a professional who coaches postural awareness or postural consciousness, such as someone trained in Feldenkrais or the Alexander Technique, can be very helpful. Any of the disciplines that teach movement therapy are a powerful adjunctive to good bodywork, and vice versa.
There are numerous exercises that someone with hammertoes can do to start to get their body back on the coronal plane. If projection is the primary pattern, then stretching of the hamstring, gluteal and low-back muscles is essential.
With projection, the hamstrings will be tight because they will be holding up the body, rather than the femur, leaving them locked in the eccentric position. If both flexion and projection are involved, the quadriceps needs to be stretched as well.
A person with both a forward-head posture and an accentuated lordotic curve will need to flex the cervical spine anteriorly to stretch the splenius capitus, cervicus and erector spinae.
Also, if the shoulders are rounded, which can be another reason why the body is forward, then the pectoralis muscles need to be stretched.
Stretching should be guided by someone who knows how to analyze the body structurally and also knows proper stretching technique. This is essential because hammertoes are both a pelvic problem and a forward-head problem, so applying the proper knowledge would mean the difference between treating effects and treating causes.
About the Author
Paul St. John, LMT, CINT, founder of the St. John Method of Neuromuscular Therapy and Integrative Neurosomatic Therapy, has been treating clients and educating manual therapists and other health care professionals for more than 30 years.