My Toes Used to Line Up Straight. What Happened?

Jan Spalding Medical 0 Comments

        As we approach the colder months, many sports are well within their season or just about to begin. However some individuals may be taking this opportunity to rest, cross-train and plan goals for next year. During this time, it’s wise to assess the stresses that your favorite activity is having on you and plan realistic goals for continuing it throughout your lifetime.

        In the course of an active lifestyle, you will no doubt feel the effects of impact within your musculoskeletal system. Some of these effects are good—such as the maintenance of bone density and muscle tone. However some are bad—such as arthritis or structural compromise. While there are a plethora of maladies that can fall within this realm, there is one in particular that is found consistently within my clinics. This is a group of disorders characterized by a malposition of the lesser toes, collectively referred to as “hammer toes.”

        As the toes fail to align themselves, the pressures surrounding them can change the way the forefoot works in conjunction with the kinetic chain of the lower extremities. The most common outcomes from this progressive disorder would include: callouses, skin ulcers, nail changes, neuromas, pain in the metatarsals, and destruction/displacement of the underlying fat pad to the forefoot.

Anatomy

        The shallow articulation of a toe with the foot can be compared to the way a golf ball articulates with the tee. As such, the balancing forces of the muscles, ligaments and bony relationship within the entire foot and ankle can affect the toe’s position, including the intrinsic muscles (muscles that originate and insert within the foot) as well as muscular extrinsics, (muscles that originate outside of the foot such as the leg, but insert within the foot.)

         Due to biomechanical dysfunction or overt trauma, a displacement of the pull surrounding the toe can occur placing it in one of several common malpositions.

Causes of Hammer Toes

While there are many conditions contributing to the formation of hammertoes including: trauma, systemic disease and peripheral neuropathy, there are three common biomechanical etiologies. Once understood, steps can be taken to arrest their progression.

Flexor Stabilization occurs in an (over)pronated foot as your heel lifts off, and you propel forward with each step. This will result in a predictable incurvation of (usually) the outside two toes. Many times with this type of position, a callous may occur on the outside border of your toenails, or a soft callous (heloma molle) may develop between the toes as the boney prominences rub together.

Flexor substitution occurs in an (overly)supinated foot in which the contracting muscles on the bottom of the foot/toes, overpower those between the metatarsals. This will usually result in a straight contracture, with skin breakdown at the tips and dorsum of the affected digits.

Extensor Substitution, unlike the other two occurs in the swing phase of gait as the result of a tight Achilles tendon. As a result, the extensor tendons from the anterior leg are fighting against the tightness in the soleus and gastrocnemius of the posterior compartment. Over time, “form follows function” and the toes simply remain dorsiflexed at the bases and plantarflexed at the mid-joints. This will traditionally carry the fat pad of your foot forward, leaving the metatarsal heads prominent on the bottom of your foot. This like Flexor Substitution can leave you vulnerable to skin breakdown on the dorsum or tips of the digits.

What you can do

Pay attention to your genetics. While hammer toes are not necessarily a genetic trait, your stature and function are. As such, your inherited tire alignment will likely result in a predictable tread wear similar to the generations before you.  Take the time to self-assess structural changes in your body as you get older, … just as we watch for things like maximum heart rate and aerobic capacity.

Wear appropriate shoes that fit well (like they were made for you), and replace them every 6 months with regular use.  If you feel that you could benefit from an over-the–counter arch support, give it a try. These are inexpensive, and do little harm if used with caution.

Stretch! Of all people who know the importance of flexibility (especially over 40), I even find myself not always stretching as well as I should. Of noteable importance is the runner’s stretch, which is particularly beneficial after a workout when your tissues are most pliable.

What your doctor can do

If you find the need for help beyond that of good solid training habits, your physician can help in several ways.

1. It’s always difficult to self-assess your own biomechanics, as the subtleties need to be observed from an outside perspective. I’ve seen a great deal of literature on analyzing a person’s golf swing, but the same holds true for runners. Your podiatrist will be able to evaluate subtleties in your shoulders, hips, knees and ankles that may go unnoticed from your perspective. This will also be correlated to strength, flexibility, symmetry, and assessed for any imbalances.

2. Any malposition or new prominences can be evaluated radiographically. X-rays are a great way to see where you are today, and can be used to correlate an expectation for the future—as many changes in the feet follow a predictable pattern of progression.

3. If your hammer toes are flexible, there is a chance that they can be controlled conservatively with a gain in flexibility (in other areas of your lower extremity) as well as treating the biomechanical cause with custom orthotics.

4. If your hammer toes are rigid with pain or breakdown of the skin, there is a chance that surgical intervention will be needed to restore function and offload the malposition. As always, your podiatrist will explain the risk vs. benefits of such a procedure and help determine if this is the right course of action for you.

Run safely my friends and have a safe and healthy holiday season.

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