Initial Management of Hammer Toe Referrals from Primary Care

Risk Stratification and Assessment

The American Diabetes Association recommends assessing for peripheral neuropathy using 10-g monofilament testing or vibration assessment, as loss of protective sensation dramatically increases ulceration risk 1, 2, 3
Evaluating vascular status by checking pedal pulses and considering ankle-brachial index if pulses are diminished is crucial, as peripheral arterial disease affects healing capacity 1, 2, 4
Inspecting for pre-ulcerative signs, including erythema, warmth, callus formation, or hemorrhage under callus, indicates areas of impending tissue breakdown 1, 2, 5
Documenting the presence of other bony deformities, such as prominent metatarsal heads or bunions, compounds pressure distribution problems 1, 4

The American College of Foot and Ankle Surgeons recommends extra-wide or depth shoes to accommodate the hammer toe deformity without creating pressure points 1, 2, 5, 4
Shoes should be 1-2 cm longer than the foot with width equal to the foot at the metatarsophalangeal joints, assessed while standing 6, 7
Regular callus debridement by a trained foot care specialist prevents pressure buildup that leads to ulceration 1, 8, 9, 3
Daily foot inspection, focusing on areas of redness, particularly between toes and under metatarsal heads, is essential 1, 5, 3, 7

The International Working Group on the Diabetic Foot recommends digital flexor tenotomy for high-risk diabetic patients with hammer toes and pre-ulcerative signs or ulcers on the distal toe when conservative treatment fails 8, 9
This procedure showed 0-20% recurrence rates in case series with 11-36 months follow-up, and no ulcer occurrence in 58 patients with impending ulcers 8, 9

Integrated foot care programs, combining professional foot care, repeated patient education, and appropriate footwear on a regular basis, significantly reduce ulcer recurrence 8, 9
Home temperature monitoring of foot skin can identify early inflammation before ulceration develops 8, 9
Regular professional foot care is valuable, as canceling preventative podiatry coverage increased hospital admissions for diabetic foot ulcers 8, 9