There comes a time when you decide that nothing else will make your pain go away other than hammertoe surgery.

With great care your surgeon has explained the details of the surgical procedures, discussed with you the things that could go wrong since this is not a perfect world, and developed a game plan for recovering from surgery to achieve the best possible outcome.  At least at Geller Podiatry, this is how it is done.

A great deal of information gets exchanged, but ultimately the days or weeks leading up to your surgery are busy planning for the big day.  You need to schedule time off from work, someone to help with household chores, care for the kids and their needs.  I’ve already written about planning before surgery, but there are little things that can make a huge difference.

What is the biggest obstacle to healing your hammertoe surgery?  After thousands of hammertoes treated at Geller Podiatry the one thing that differs between easy and difficult recovery from surgery is swelling.  Remember what I always say, “You can’t start to heal until inflammation is gone”.  Well one of the key signs of inflammation is swelling.

Toes are small.  There isn’t much room for them to swell.  Increased pressure on nerves causes more pain.  Increased pressure on your circulation to the toe makes healing take longer.   Patients who control swelling from day 1 always have a faster recovery.

The key to controlling swelling:  “RICE”

Rest, Ice, Compression, Elevation

Rest:

The way I discuss surgery with my patients always involves this statement: “No matter how minor you think this surgery is going to be, you need to treat it like it is major surgery”.  If you think you are going to pick up where you left off one or two days after surgery, think again!  Your daily routine will have to wait for your recovery, that’s why we plan before your operation.  First of all rest involves lying down, not just sitting.  you will be prescribed a boot to wear on your foot.  This boot is also part of rest.  The area of surgery will be protected or rested while wearing the boot.  Do not remove the boot until you are told that this is OK.

Ice:

In all of my years of experience I would have to say that ice is possibly the most under-rated anti-inflammatory in the world.  There are some simple rules you need to follow when using ice: 1.  do not put ice directly on your skin; 2. ice is applied for 20 minutes and then left completely off for 40 minutes.  Ice is usually applied to the ankle or behind your knee.  My patients tell me that behind the knee is the easiest and if it’s easy you are more likely to do it.  Put a washcloth over the ice pack and then rest your knee on the ice.  If you leave the ice on for more than 20 minutes or without protecting your skin you could develop a cold injury or frostbite.

Compression:

Keeping snug bandages on your foot help to prevent swelling.  There is a difference between snug and tight.  The appropriate amount of compression is still comfortable.  If your compression is applied too tight you will notice things like the toe changing color, usually blue, but white can also occur.  Numbness and tingling can occur when the bandages are too tight.  If these are noticed call your surgeon and loosen the bandage.  The layer of bandage that supplies the compression is always the outer most layer.  If you need to loosen compression only touch this outermost layer, nothing beneath it without your doctor’s permission.

Elevation:

This is the easiest part, but the one most people fail to do.  Elevation of a foot means getting your foot above your heart.  Remember that the heart is in your chest, so you have to lie down and get your foot up on pillows or the arm of a couch.  A helpful hint is to keep your knee bent slightly for comfort.

A Geller Podiatry, our team spends a tremendous amount of time with you planning for your surgery.  These simple steps are what we see as making the biggest difference between what patients consider an easy recovery vs. a difficult recovery.  Rest, ice, compression, and elevation (RICE) is an old standard because it works.  Don’t underestimate the power of RICE.  I hope you have a wonderful surgical experience when you decide to have your hammertoe surgically corrected.

screw and absorbable pin

So your toe is bent to the point where your shoes rub on the top of your to causing pain.  The skin is always red and sore.  The bending has gotten worse over the past year and at times you have pain in the ball of your foot.  What if I told you I could fix the bend in your toe so that the pain goes away?  Take it one step further, I can fix the bend in your toe so that the pain goes away, but there will be a pin sticking out the end of your toe for 4-6 weeks.  For a lot of people that’s a deal breaker.  They want the toe fixed, are willing to deal with the pain and recovery of hammertoe surgery, but don’t want to see that pin sticking out the end of their toe.

This is a big problem and as your surgeon I have to address your concerns.  I recognized this early in my training and began using absorbable pins that did not stick out of the toe while I was a resident.  Smaller screws became available that could be used in toes and more recently special little devices made of space-age material were introduced just for toe surgery.

I’ve already talked about the difference in hammertoe surgery between the 2nd and 3rd toes as compared to the 4th and 5th.  Here I’m talking about the 2nd and 3rd toes only.  When I fix the bend in your toe I need to make a stiff, straight toe.  I remove the crooked joint and force the bone to heal together straight.  That’s why I need to use a pin, screw, or special little device to get the bones to heal together, or in other words fuse.  The only question to ask for this part of your surgery is how strong is your bone?  That changes my options.  Stronger bone means I can use just about anything, but weaker bone limits my options.

Why do some people still have hammertoe surgery with the pin sticking out of the end of the their toe?  The most common reason is weak bone.  Some things that have been around a long time are still used today because they work in almost every case.  Even if your bone is weak a pin can be used to hold it straight until healed.  The other reason is the joint at the base of our toe where your foot begins.  Many people have toes so badly bent that the joint in the ball of their foot is also bent.  More recent advances have shown that breaking the bone in the ball of your foot to straighten this joint is better than the older method of cutting tendons and ligaments.  When we used to cut the tendons and ligaments in this area the best way to hold the toe straight was using a long wire.  Now we use screws to hold the bone in the ball of your foot without having to use a pin across that joint.

smart toe

New techniques and new technology are sometimes slow to catch on.  Hammertoe surgery without the pin sticking out of your toe is not new.  As I said in the beginning, I started doing this when I was in residency.  I’ve been training residents for about ten years and even the very first resident I taught learned how to fix a hammertoe without a pin sticking out the end of the toe.  When I discuss toe surgery with you I will talk about the options and what I think is best for you.  I want to hear your opinion and make sure I’m addressing your goals.  It is very important that we are on the same page when it comes to fixing your toe.

Hammertoe toe surgery might be in your future.  If you are scared about having a pin sticking out the end of your toe come and talk to me.  More often than not I can straighten your toe without having to leave a pin sticking out the end.

I guess it’s the training I received combined with a dry sense of humor and no nonsense approach that filled my practice with patients other doctors considered too hard to heal.  Because of the level of patient I treat at Desert Foot Surgeons, I take your recovery seriously as should you.  The most prefect surgery can still hurt, swell, and even go horribly wrong if you’re not on the same page as your doctor.  I have many patients who can run a mile in under 6 minutes, but their recovery might not be as fast as a patient who smokes.  If we work together, even patients with diabetes who have sores on their feet can heal.

With that said, recovering from hammertoe surgery is usually not that hard.  You should do a few thins to make sure that your healing experience is the most pleasant possible.  Before your surgery is the most important time.  The more you can do for yourself before surgery, the happier you will be after.  Simple things like preparing meals before hand, practicing walking in your special shoe or boot, and planning for time spent resting your foot.

What room in your home worries me most?

Believe it or not it’s your kitchen.  Those kitchen cabinets have that little ledge at the bottom.  Be careful not to hit your toes against this edge.  The shoe or boot you will be wearing is higher than regular shoes and has grabbed hold of more than one of my patients’ bandages.  That’s a good reason to prepare meals before your surgery, but the real reason is you are recovering from surgery.  You shouldn’t have to cook for yourself.  Give yourself at least a little few meals off to rest and stay off your foot.

Since we’re talking about hammertoe surgery most of you will be allowed to walk, but in a special shoe or boot.  You might not think this is going to be hard, but if you’re weak this can be a challenge.  I can send you to physical therapy before the surgery to be sure you can handle the shoe or boot.  This way you and I know exactly what to expect after surgery.  I can even prescribe a strengthening program for you through physical therapy if you need.

Easier Hammertoe Recovery

Other things that can make your recovery from hammertoe surgery easier include getting your house set.  Firsts of all, do you have stairs?  If walking on flat floors is hard in the shoe or boot, stairs might be impossible.  You might want to sleep downstairs the first few days.  You will need to clear a path to the bathroom.  Think about removing area rugs that can slip and slide out from under foot.  Small tables and chairs can have legs that stick out, which could bump your toe.  Think about the ways you can set up your house to help you recover.  My staff has many more ideas that they will be glad to share with you.

Before surgery we developed a plan to help you heal as fast as possible.  After your surgery you need to stick to the plan.  The game plan we designed together before surgery will be given to you in writing.  Obviously there will be a special shoe or boot and pain medication that you should have before you get to the hospital.  That leaves swelling and pain to discuss.  A toe is small and there is not much room for swelling.  The more your foot is down, the more it will swell.  Since there is so little space in the toe this swelling can hurt.  Both of us want your surgery to be as free of pain as possible.  You will need to rest with your foot up.  That means lie flat on the couch or bed and put your feet on pillows.  Make sure your knees are bent a little so this is more comfortable.  Ice can go behind your knee or at the inside of your ankle to prevent swelling.  The ice should be on 20 minutes and then off for 40 minutes.  This can be repeated as often as needed, but usually no less than 3 times per day for the first 3 days.

I like to prepare before surgery as much as possible.  I tell my residents to review a surgery in their mind 5 times before they even step into the operating room.  If your surgeon prepares before surgery shouldn’t you?  I hope this information shows you how Desert Foot Surgeons helps you heal after hammertoe surgery.  Remember, feet are like snowflakes, no 2 are alike.  Choosing your foot surgeon is very important.  Your surgeon needs to have the training and artistic talent to fix your toe.  Equally as important is your ability to communicate with your surgeon.  Ask questions and prepare before your surgery.  You’ll be glad you did.

So you’re at the point where you need surgery to fix your hammertoes and you want more information.  They way I fix your toe depends on the cause and there are 3 causes of hammertoes.  These different causes make the toes bend and twist in different directions.  Your 2nd and 3rd toes will bend in a straight line, but your 4th and 5th toes twist as they bend so the nail doesn’t sit on top of the toe any more.  Just to clarify, your little toe is #5 and your big toe is #1.  Counting from your big toe to the little toe goes 1, 2, 3, 4, and 5.

Let’s start with your 4th and 5th toes.  Unfortunately shoes press the hardest on your 4th and 5th toes.  Because of this constant pressure I can’t make these toes stiff or you would never wear shoes again without pain.  In fact, your 4th and 5th toes are fixed by removing the crooked joint and leaving the toe flexible.  Removing the joint will fix the bend, but does nothing to fix the twisting so I have to use a carefully planned skin incision to un-twist your toe and bring the nail back on top.  The bandages will help to hold your toe in this position since there are no screws or pins, so it is very important that you do not remove your bandages.  To prevent the tendons from pulling on your toe you must wear a special shoe or boot.  You will be allowed to walk after the surgery as long as you wear this shoe or boot, but remember that the more time you spend walking around on your foot after surgery the worse the swelling and pain will be.  Stitches are removed after 10 days and you will wear a loose fitting tennis shoe before you return to tighter shoes.  I expect swelling to last 3-6 weeks, but a lot of that depends on your body.

Your 2nd and 3rd toes are more complicated to fix than the 4th and 5th because they buckle for a different reason.  Because of this difference I have to treat these toes using another approach.  Your 2nd and 3rd toes must be made stiff so that the muscles won’t cause the toe to buckle again after it has been fixed by surgery.  That means that after the surgery your 2nd and 3rd toes will not bend at the toe joint.  You will have a screw or pin in your toe to hold the bones straight.  The screw or pin can be removed in the office at a later date if needed.  No doubt you have heard stories about people having pins sticking out of their toes after hammertoe surgery.  I use newer technology when I can so that you won’t have anything sticking out of your toe.  It is still important that you not change the first set of bandages after surgery.  In straightening your 2nd and 3rd toes I am removing the crooked joint and making the bone ends heal together.  You will be able to walk using special cast boot, but again the amount you walk determines how much swelling and pain you get.  The bone takes about 1 month to heal.  Tennis shoes are easier to wear at first and as swelling and pain subside you can progress to the shoes you want, within reason.

That’s the scoop on the most common hammertoe surgeries.  I’ve told you how fixing your 4th and 5th toes are different from your 2nd and 3rd.  You have an idea of what to expect after surgery.  I have not told you about the more complex toe problems, but will in future posts.  For now remember what I always say, “feet are like snowflakes, no two are alike”.  The surgical approach from one foot to another has to be different, that’s the art of surgery and is one of the main things separating me from other foot surgeons you might meet.

Toes that are bent or buckled hurt when you put them into shoes. Parts of the toe can rub against shoes making areas of hard skin, known as corns. These can be reduced by your podiatrist, but will never resolve unless the toe is straightened. Changing the shoe to keep pressure off the toes might not be possible depending on how severe the toe is buckled.

The treatment differs based on the stiffness of the bent toe. Smaller toes such as the 4th or 5th that can be straightened by hand often can be treated by simple tendon release. This is the easiest hammertoe surgery to recovery from often requiring a single stitch. If more than one toe is done at a time the recovery can be slightly longer.

If the bend in the toe cannot be straightened by hand, removal of the rigid joint is performed. At Geller Podiatry we employ a detailed step-wise approach to straighten all parts of the toe. The more deformed the toe, the more steps will be used from simply fusing the toe joint straight to breaking the metatarsal head and repositioning the entire toe. Tight skin has to be lengthened using plastic surgery techniques so that the toe can stay straight and the scar is more cosmetic. In general these procedures require protection from walking using a cast boot. X-rays are used to follow the toe healing process and you will be returned to shoes when your doctor sees evidence of bone healing.

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Hammertoes
Hammertoes
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Hammertoes develop when the toes buckle under the pressure of walking on an unstable foot. When your foot pronates too much, the muscles work harder to support your arch. If your foot remains unstable the toes bend as muscles fight to prevent the arch collapsing while you walk. Left untreated the toes will stay curled leading to corns, calluses, and pain.

Early treatment is important. At Desert Foot Surgeons we perform a detailed examination including video gait analysis to identify the reason for the unstable arch. If you do not correct the true cause of the problem it will only return. Foot orthotics are used to stabilize the arch and prevent hammertoes in the early stages. Once the toes stay bent treatment involves changing the shoes that push on the painful toe or surgically straightening the toe.

Dr. Stephen Geller, AZ Podiatrist