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.