Hammertoes look simple from the outside, a bent toe that rubs in a shoe, but the decision to operate versus splint is rarely that simple. I have treated office workers who just need to get through an eight-hour day in dress shoes, marathoners nursing calluses at mile 18, and seniors whose toes have curled enough to threaten skin breakdown. The right plan depends on the toe’s flexibility, the forces driving the deformity, the condition of the skin and nerves, and the patient’s goals. A board certified foot and ankle surgeon weighs more than X-rays. We study how you stand, how you roll off the ball of your foot, and how your footwear, ligaments, and tendons share the load.
This guide unpacks how an experienced foot and ankle specialist thinks through hammertoe care, where splinting and other conservative care shine, and when a foot surgery specialist recommends operating. I will also walk through surgical options, recovery timelines, and the practical trade-offs I discuss every day in clinic.
What is a hammertoe, really?
A hammertoe is a sagittal plane deformity affecting the small toes, most often the second, sometimes the third or fourth. The proximal interphalangeal (PIP) joint flexes, the metatarsophalangeal (MTP) joint may hyperextend, and the distal interphalangeal (DIP) joint can flex or extend depending on tendon balance. Early hammertoes are flexible, which means you can straighten the toe with your fingers. Over time, the soft tissues adapt, the joint capsule tightens, and the deformity stiffens. Corns arise from shoe friction over the PIP joint, and calluses under the ball of the foot reflect shifted pressure.
Not all bent toes are the same. A mallet toe involves the DIP joint only, a claw toe shows MTP extension with both IP joints flexed, and a hammertoe focuses at the PIP. The driving forces vary: a long second metatarsal that overloads the toe, a bunion that crowds the second toe, calf tightness that tilts mechanics forward, or a plantar plate injury that destabilizes the MTP joint. A foot and ankle orthopedist or a podiatric surgeon should trace the root cause, not just treat the bump you can see.
The everyday calculus: symptoms, structure, and goals
In my exam room, I split the conversation into three lanes.
First, symptoms. Pain that limits walking, work, or sport carries more weight than how the toe looks. Pain from a corn over the PIP joint behaves differently than a burning ache beneath the metatarsal head. If the skin has ulcerated, especially in a person with diabetes or neuropathy, the urgency changes.
Second, structure. I check whether the toe is reducible with gentle pressure, how tight the extensor and flexor tendons feel, and whether the MTP joint is stable. I look for a crossover toe, where the second rides over the big toe, a sign of plantar plate attenuation. Weightbearing X-rays tell me about metatarsal length, joint space, and alignment. A flexible hammertoe in a shoe that does not fit is a different problem than a rigid toe with a contracted capsule and dislocated MTP joint.
Third, goals. A nurse on 12-hour shifts, a ballet dancer needing plantarflexion, and a retiree who just wants to walk the dog have different thresholds for intervention. Shoes matter. Occupation matters. Timelines matter. As a foot and ankle surgery provider, I always ask what a good outcome looks like to you.
When splinting makes sense
Splinting, padding, toe spacers, and taping address symptoms and sometimes slow progression. I reach for them in three scenarios: early flexible deformity, mild pain that ties to footwear, and patients who cannot or prefer not to undergo surgery. A soft gel sleeve over the PIP joint can stop a corn from rubbing. A loop-and-strap hammertoe splint can pull the toe straighter inside a wide, deep toe box. Taping under the toe to the plantar surface supports a sore plantar plate. Night splints have a narrow role but can help certain flexible toes.
Footwear changes do the heavy lifting. A shoe with at least a thumb’s breadth of extra length, a deep toe box, and a rocker sole can unweight the PIP joint and reduce forefoot pressure. I have shifted more symptoms with the right shoe than any single piece of hardware. Custom or semi-rigid orthoses redistribute load under the metatarsal heads, especially in a long second metatarsal. Calf stretching and intrinsic foot strengthening improve mechanics. None of this straightens a rigid toe, but all of it can reduce pain in a flexible one.
Caveat: splinting can aggravate an unstable MTP joint if it forces the toe down without addressing the proximal instability. If your toe drifts or crosses over, poorly directed straps can worsen it. An experienced foot and ankle surgical specialist will show you how to apply support that lifts at the MTP and gently flexes the PIP, rather than the reverse.
When splinting falls short
Splints treat friction and mild imbalance. They do not reverse capsular contracture, bone adaptation, or severe tendon tightness. A few signs tell me conservative care has hit its ceiling.
If the toe is rigid and the PIP joint does not straighten with gentle pressure, the soft tissues have adapted to the point that padding can only cushion, not correct. If there is a well-formed corn that keeps returning within weeks despite proper shoes and gel sleeves, the underlying prominence likely needs structural change. If the MTP joint is unstable or dislocated, taping can soothe but rarely restores alignment long term. And if a neuropathic patient has recurrent ulceration over a hammertoe, leaving the bony pressure point may be unsafe.
People often test the limits themselves. I had a distance runner with a flexible second hammertoe who did great on a stiff-rocker shoe and toe sleeve for two seasons. When the toe became rigid and the corn returned after every long run, we had an honest talk about the risk of surgery against the quality of her training life. She chose an operation in the off-season and returned to marathons with no PIP pain.
Red flags that shift the threshold toward surgery
Certain findings move surgery up the list. Recurrent ulcers over a hammertoe in a person with diabetes, even tiny ones, risk infection and bone involvement if the pressure continues. A crossover second toe that rides high often reflects a torn or stretched plantar plate that won’t recover with splints alone. Painful MTP synovitis with joint subluxation is another warning sign. And a stiff toe that crowds neighbors can drive a cascade of new corns and bunions.
Skin quality matters. If the skin is at risk, the calculus changes. In neuropathy, the protective sensation is gone, so friction injuries can progress silently. In those patients, I will often discuss earlier structural correction to remove the pressure point rather than chase dressings and pads.
What surgery actually does
Surgery straightens the toe by rebalancing tendons, releasing contracted soft tissues, and in many cases shortening or fusing bone to lock in a corrected position. The specific plan mirrors the deformity pattern.
In a flexible hammertoe with mild MTP extension, a soft tissue release at the PIP, sometimes paired with a flexor to extensor tendon transfer, can realign the forces. When the toe is rigid, a PIP arthrodesis, which removes the joint cartilage and fuses the bone straight, becomes the cornerstone. Modern intramedullary implants can hold the position without an external pin, but K-wires remain common in straightforward cases and are removed in clinic after several weeks.
When the MTP joint is unstable or the toe crosses over, I address the plantar plate. A direct plantar plate repair or a dorsal approach with suture anchors tightens the base of the toe. If the second metatarsal is long and overloaded, a small dorsal wedge osteotomy shortens and lifts it a few millimeters to reduce pressure. If a bunion crowds the toe, correcting the bunion at the same sitting can be the difference between short-term relief and durable alignment.
For mallet toes, a DIP arthroplasty or arthrodesis focuses on the distal joint. For claw toes driven by neurologic imbalance, procedures may be more extensive and tailored, sometimes involving tendon foot and ankle surgeon near me lengthenings and selective fusions.
A minimally invasive foot and ankle surgeon may use percutaneous techniques for certain PIP fusions and metatarsal osteotomies. Small incisions can reduce soft tissue trauma and swelling, but the principle remains the same: realign and rebalance.
What I tell patients about results and risks
No operation is a magic wand, and a frank conversation builds the best outcomes. The vast majority of patients enjoy significant pain relief, easier shoe wear, and toes that sit straighter. A small percentage have residual stiffness or mild recurrence, and the risk climbs with severe MTP instability, unaddressed bunions, long-standing rigid deformities, or systemic factors like rheumatoid arthritis.
Risks include infection, nerve irritation with some numbness near the incision, delayed bone healing or nonunion in a fusion, pin site infection if a K-wire is used, floating toe where the toe does not make full ground contact, and in rare cases complex regional pain syndrome. Smoking, poorly controlled diabetes, and vascular disease slow healing and raise complication rates. A certified foot and ankle surgeon will screen and help optimize these risks before recommending an operation.
Recovery in real terms
People often ask how long they will be off their feet. The answer depends on how much we do and how stable the correction is. For an isolated PIP arthrodesis with a stable implant or pin, protected weightbearing in a postoperative shoe begins right away or within a few days, usually on the heel or lateral foot, avoiding direct push-off. Swelling peaks in the first two weeks, then gradually recedes over six to twelve weeks. Stitches come out around two weeks. If a pin is used, it is commonly removed at three to four weeks in the clinic.
When we add a plantar plate repair or a metatarsal osteotomy, I often limit forefoot push-off for four to six weeks, then transition to a stiff-soled sneaker. Return to desk work can be as quick as one to two weeks if you can elevate the foot. Jobs that demand prolonged standing may need six to eight weeks. Running and impact sports typically return between 10 and 16 weeks, sometimes later with more complex reconstructions. Swelling can linger for several months, especially by the end of the day. I tell patients to expect their shoe fit to keep improving through month six.
Physical therapy is not always necessary for a straight-forward hammertoe fusion but can help restore gait and manage swelling when the MTP joint https://batchgeo.com/map/foot-ankle-surgeon-rahway was involved. Simple home exercises to move the MTP, raise the arch, and stretch the calf speed the transition back to normal shoes.
A practical way to decide: splint or operate?
Two questions clarify the path. Can you wear a comfortable shoe with an appropriate toe box, and does padding or splinting keep you pain free through your daily demands? If yes, there is no prize for having surgery early. Monitor the toe, respect your skin, and keep your calves and intrinsic muscles flexible and strong.
If you have rigid deformity, recurrent corns or ulcers, progressive MTP drift, or pain that limits basic function despite good shoes and splints, structural correction likely serves you better. A foot and ankle surgical expert can explain the specific changes needed for your toe rather than a one-size-fits-all fix.
Special situations that change the plan
Athletes have a narrow window for disruption and ask a fair question: will this change my push-off? After a PIP fusion, the toe does not hinge at that joint, but a stable, straight lever often improves push-off compared to a painful, cocked toe that never contacts the ground. The second MTP joint is the engine for many athletes. If it is unstable, a robust repair and a precise rehab plan matter more than the choice of implant.
Neuropathy and diabetes deserve extra care. A seemingly small hammertoe can be the pressure point that opens a wound. When ulcers recur over the PIP despite good shoes and pads, a targeted procedure to straighten the toe and remove the pressure often prevents bigger problems. Here, the goal is protection and shoe tolerance more than perfect aesthetics.
Rheumatoid and inflammatory arthritis can soften ligaments and create multiple claw toes with MTP subluxations. Isolated procedures sometimes fail in that setting. A foot and ankle surgical consultant will discuss combined strategies, from metatarsal head procedures to multi-toe fusions, tailored to the disease activity and your activity level.
Bunion overlap creates a crowded forefoot. Fix the bunion without releasing a rigid hammertoe, and the second toe may still rub. Straighten the second without creating space at the first ray, and the deforming force persists. A comprehensive plan that sequences both problems, sometimes in one surgery, often outperforms piecemeal fixes.
What “minimally invasive” really means here
People ask for minimally invasive foot surgery because they picture faster healing and less pain. Small incisions can deliver those benefits, but only when the procedure matches the pathology. A percutaneous PIP arthrodesis can be elegant for a simple rigid hammertoe. A plantar plate repair still demands careful access, whether through a small dorsal window or a plantar approach. The right question is not, can this be done through a tiny incision, but, will this method correct the deformity completely and predictably for my foot. The best foot and ankle surgeon uses the least traumatic technique that accomplishes that.
Shoes and orthoses after surgery
When surgery goes well, the new baseline should be a toe that fits shoes more easily. I still coach patients on equipment. A forefoot rocker eases MTP load, especially after plantar plate work. A flatter insole under the small toes reduces pressure on a fused PIP joint. If we shorten a long second metatarsal, a custom orthotic can fine tune the load across the forefoot. And for those who wear narrow dress shoes for work, I give a clear timeline for easing back and a strategy for alternating with more forgiving footwear.
Realistic expectations about appearance
Most patients care more about pain than pictures, but it helps to set a fair frame. A fused PIP joint sits straight and slightly longer visually than a toe with a flexible curve. Swelling near the toe tips can make them look puffy for months. Small differences in toe length and ground contact are common from foot to foot. What matters most is comfort in shoes, lack of friction, and confidence when you walk. Perfect symmetry is a poor goal; durable function is a better one.
A brief case vignette
A 58-year-old teacher came in with a rigid second hammertoe and a recurrent corn that bled on long days. She had tried gel sleeves, spacers, and two different wide shoes. On exam, the PIP was fixed, and the MTP had early subluxation but was still reducible. Her X-rays showed a long second metatarsal. We discussed options. She chose a PIP fusion with an intramedullary implant, a small second metatarsal shortening osteotomy, and a dorsal plantar plate repair through the same incision.
She wore a postoperative shoe and kept her forefoot quiet for four weeks, then transitioned to a stiff sneaker. At eight weeks, she returned to full days with strategic breaks to elevate. Six months later she wore her standard school shoes without pads, no corn, and a toe that touched down evenly. She told me the biggest surprise was how much the pressure under the ball of her foot improved once the metatarsal was balanced.
How to prepare if surgery is on the table
If you and your ankle and foot surgeon decide to operate, a little planning smooths recovery. Stop smoking at least four weeks before and after. Check that your A1c is in range if you have diabetes. Arrange a place to elevate your foot above heart level for the first week. Set up a simple meal plan to avoid long kitchen sessions on your feet. If you live upstairs, stage a small recovery station on the main floor. Stock a few pairs of socks that fit over a postoperative shoe. And ask for a written return-to-work note that fits your job demands rather than a generic form; a foot and ankle surgical doctor can dial this in.
Common questions I hear, answered briefly
- Will the hammertoe come back? True recurrence after a solid PIP fusion is uncommon, but adjacent issues can appear if underlying drivers, like a bunion or calf tightness, remain. Address the whole picture to reduce that risk. Do pins hurt? A percutaneous K-wire can be annoying and requires pin care, but most patients tolerate it well, and removal is quick in clinic. Internal implants avoid external hardware but are not mandatory for good outcomes. Can I fix more than one toe at once? Yes, and often we should if multiple toes share the same forces. The recovery is similar, but swelling may last longer. When can I drive? Right foot surgery delays driving longer than left. With the right foot, plan at least two to three weeks for an automatic transmission, and only when you are out of the boot or post-op shoe, off strong pain meds, and can make an emergency stop safely.
Choosing the right specialist
Titles vary across regions, but you want someone who treats forefoot deformity routinely and can speak comfortably about both conservative and surgical options. Look for a board certified foot and ankle surgeon or a foot and ankle orthopaedic surgeon who can show outcomes for hammertoe, plantar plate repair, and related forefoot procedures. Ask how often they operate on toes, what proportion of their patients they manage without surgery, and how they decide to correct coexisting bunions or metatarsal overload. A seasoned foot and ankle surgery expert doctor should welcome these questions.
Some practices market as foot and ankle surgery clinics or foot and ankle surgical practices, others as orthopaedic foot and ankle surgeons or podiatry surgeons. What matters is depth of experience, a balanced approach, and a plan that fits your mechanics and your life. Whether you see an orthopedic foot and ankle surgeon or a podiatric surgeon, you should feel heard, see your deformity explained in plain language, and understand the path ahead.
The bottom line for operate vs. splint
Splinting and thoughtful footwear relieve symptoms in flexible hammertoes and can buy years of comfortable walking. Surgery makes sense when pain persists, deformity has hardened, the MTP joint is unstable or dislocated, or the skin is at risk. The right operation targets your specific pattern, from a straightforward PIP fusion to a combined plantar plate repair and metatarsal adjustment, occasionally paired with bunion correction. Recovery is measured in weeks for basic procedures and a few months for more complex work, with steady gains along the way.
Done well, the reward is not just a straighter toe, but a foot that moves without the constant negotiation of pads, tape, and blister care. That is the standard I set as an experienced foot and ankle surgeon: durable comfort, shoes that fit, and the confidence to walk, work, and play without thinking about a single stubborn toe.