Up Big Toe - Hallux Hammertoe
The big toe,
called the Hallux, is made up of two small bones called phalanges. This
condition presents as a cocking up of the big toe at the joint between these
two small bones. In the early stages of the condition the deformity is
flexible; in later stages the deformity becomes rigid. It is caused by a
variety conditions. Neurological diseases that cause muscle weakness or muscle
imbalance in the muscles of the lower leg can result in the formation of Hallux
hammertoe. This is commonly seen in patients after they have suffered a stroke
or Cerebral Vascular Accident. Damage to certain areas of the brain
during a stroke will frequently result in weakness and/or paralysis on one side
of the body. If the stroke is not severe the patient may recover a majority of
the function of the muscles in the legs and feet. However a residual result may
be a cocking up of the big toe.
Other causes of
the condition include damage or laceration to the tendon on the bottom of the
big toe. Surgery to correct bunion deformities, in rare cases, may result in an
imbalance of the structures about the big toe joint and cause the condition. An
additional cause of hallux hammertoe is the absence of two small bones, called
sesamoid bones, which are normally present beneath the big toe joint. There is
an uncommon condition where a person may be born without these bones. More
commonly however, the absence of one or both of the sesamoid bones is due to
their surgical removal. In the course of correcting a bunion deformity one of
the sesamoid bones may be removed. In another situation, a fracture of one or
both of the sesamoid bones may result in the necessity to remove them to cure
the pain associated with the injury (See the description of sesamoiditis).
A high arched
foot may also result in the formation of, not only a hallux hammertoe, but also
hammertoes of all of the toes.
A consequence of
having a hallux hammertoe is irritation on the top of the toe from shoe
pressure or the development of a painful callus on the end of the big toe.
People who have had a stroke or who have diabetes with peripheral neuropathy
may not have pain associated with the callus on the end of the toe. These areas
may ulcerate and become infected.
The diagnosis of
hallux hammertoe is made by clinical exam. An x-ray is useful in determining
the degree of the deformity and the condition of the joint. The presence or
absence of the sesamoid bones is also made using an x-ray. If a neurological
condition has not been identified and there is absence of trauma or previous
surgery in the area, then evaluation by a neurologist may be appropriate.
The need for
treatment is based upon the level of symptoms the patient may be experiencing.
Splitting the toe in an attempt to straighten it is of little value and is
certain to fail. If treatment is needed, surgical correction of the deformity
has the greatest level of success.
If the deformity
is flexible a simple tendon release procedure can be performed. This consists
of making a small incision on the side of the toe and cutting the tendon in the
bottom of the toe. If an ulceration or open sore is present on the end of the
toe cutting the tendon to relax the toe may be all that is necessary to allow
the ulceration to heal. This procedure can easily be performed in the doctor's
office under a local anesthesia. Following the surgery a dressing is applied to
splint the toe in a straighten position. The sutures and the bandage are kept
in place for 7 to 10 days. The patient should keep their activities to a
minimum during this period of time and keep the area dry. A post-operative type
of shoe is worn to accommodate the bandage. Generally a patient can return to
normal shoes within two weeks and resume complete normal activities in three
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If the deformity
is rigid then fusion of the joint will be necessary to correct the deformity.
Under certain circumstances the foot surgeon may elect to fuse the toe when the
deformity is flexible. Fusion of the toe requires removing bone at the level of
the joint in the toe. The articular surfaces of the joint are removed and the
two small bones are abutted up against one another and held in place by a small
screw. This fuses the two pieces of bone together resulting in permeate
straightening of the toe. This procedure is generally performed in an
out-patient surgery center or hospital. The surgery can be performed under a
local anesthesia but the patient and surgeon may prefer to use a twilight
anesthesia for the patient's comfort. Following the surgery a fluff dressing is
applied. The sutures will remain in place for 7 to 10 days. During this period
of time the patient should significantly reduce their activities and keep their
foot elevated. It takes 6 weeks or longer for the bones to fuse. During this
period of time the patient should wear a stiffed-soled post-operative type of
shoe. Bending of the toe will delay or inhibit the fusion of the bones. Quite
often it takes three months before the patient can return to full-unrestricted
complications include infection, excessive swelling, and delays in healing or
failure of the bones to fuse. Overall the procedure has a very high success
rate. On occasion, over time, the screw may begin the cause irritation on the
tip of the toe and have to be removed.