My grandfather loved to hunt quail, walking the

fields and thickets of his native western Oklahoma

prairie. At some point toward the end of his life, he

switched from walking to driving, hanging his shotgun

out the window of his old sedan, slowly cruising the

back roads, still looking for quail. “It’s my hammertoes,”

he’d say. “Just can’t walk around like I used to.”

A hammertoe is bent downward (Images 1 and 2), resulting in painful pressure on the end of the toe or its upper side where it rubs or hits the shoe. Common causes and risk factors include:• Wearing narrow or tight-fitting shoes. • Imbalanced muscle strength, tonus, or flexibility in the

foot or leg. • Direct trauma or injury to the structures involved. • Genetic influences such as Morton’s toe, in which the second

toe is longer than the great toe, making it more likely to hit the end of the shoe.

• Neuromuscular diseases (e.g., cerebral palsy, Charcot-Marie-Tooth disease, multiple sclerosis), inflammatory diseases (e.g., psoriasis, rheumatoid arthritis), and the nerve damage sometimes accompanying diabetes.

The second toe is most often affected (Image 2), though hammertoe can be found in any of the toes. In a “true” hammertoe, the joint at the base of the toe (the metatarsal phalangeal joint, or MTPJ) and the next joint (the proximal interphalangeal joint, or PIPJ) are fixed in a bent position. Variations include mallet toe (when the contracture is primarily at the most distal interphalangeal joint, or DIPJ); claw toe (flexure at all three toe joints); crossover toe; and clinodactyly (congenitally curly toes). Although our discussion will focus on hammertoes, the principles and techniques here can be adapted to address these other conditions as well.

Although seen in all ages, hammertoe incidence increases with maturity, eventually affecting about one in 10 people over the age of 60. Hammertoes are about five times more likely in females than males (perhaps because women tend

112 massage & bodywork may/june 2012

techniqueBodyReading the MeRidians | @woRk | essential skills | Myofascial techniques

working with hammertoes: the FootBy Til Luchau

Hammertoes range from moderate ( Image 1) to severe ( Image 2). Remedies include spacers and splints ( Images 3 and 4), exercises, and surgery ( Image 5). Images 1 and 2 courtesy Primal Pictures; Image 3 courtesy CorrectToes.com; Image 4 courtesy PediFit.com; Image 5 courtesy James C. Mutter, Kamran Jamshidinia, MD. All used by permission.

1 2

3

45

to wear tighter shoes than men—studies claim that nine out of 10 women wear shoes that are too small).1 There are racial differences too, with hammertoes about three times more frequent in African-Americans under the age of 60 than in whites of the same age (though there is much less racial difference in people over 60).2

Nonsurgical care of hammertoes involves using more spacious shoes; padding points of contact; using special braces, spacers, or splints (Images 3 and 4); physical therapy; and exercises such as using just the toes to gather and ungather a towel on a hard floor.

Whatever the root cause or factors involved in hammertoes, the result is that the soft tissues are too short to allow natural alignment of the toe bones. Surgeons address this by one or more of these methods (Image 5):1. Lengthening the contracted

connective tissue by cutting toe tendons, capsules, or ligaments.

2. Shortening bones to fit the contracted tissues by removing articular heads or other parts.

3. In advanced cases, performing arthrodesis (fusion) of the bent joints via wires or other means in combination with the two methods above.

Although some consider hammertoe surgery easy to perform (it is often the first surgery new surgeons are allowed to do),3 complications do occur, most commonly pain and discomfort related to the loss of movement in the toe, especially when joints have been excised or fused.

As manual therapists, there are many ways we can effectively release the shortened soft tissues involved in hammertoe and related conditions. Sometimes this is corrective, reversing the curling of the toes, and other times it is palliative, meaning that it helps relieve pain and other symptoms. It also is reasonable to imagine that soft-tissue lengthening could, at least in some cases, delay or prevent hammertoe surgery, and so avert the resulting loss of mobility that patients often experience after corrective surgery.

Ida Rolf, the originator of Rolfing structural integration, said, “In a balanced body, when flexors flex, extensors extend” (Image 6). Nowhere is this more obvious than in the toes. When toe flexors contract without reciprocal lengthening of the extensors, the toes are pulled short from both above and below. The toes can’t collapse like a telescope, nor is it easy for them to bend sideways, as the great toe does in hallux valgus, or bunions; therefore, the middle toes shorten by buckling into a hammer, mallet, or claw shape (Image 7), depending on the shape of the joint involved, and on the structures that are responsible for the pulling.

In normal movement, toe flexors and extensors take turns contracting and lengthening ( Image 6). In hammertoes ( Image 7), both flexors and extensors remain contracted simultaneously, buckling the toe. Over time, the ligaments and joint capsules shorten, further fixing the joint. Image 6 courtesy Primal Pictures; used by permission. Image 7 courtesy Advanced-Trainings.com.

6

7

extensors

Flexors

Watch Til Luchau’s technique

videos and read his past

Myofascial Techniques articles

in Massage & Bodywork’s digital

edition. The link is available at

Massageandbodywork.com, at

ABMP.com, and on Advanced-

Trainings.com’s FaceBook page.

ABMPtv.com “Extensor & Flexor Digitorum

Brevis Technique”

Celebrate ABMP’s 25th anniversary and you may win a refund on your membership. ABMP.com. 115

MyOFAscIAL TEchnIquEs

FLEXOR DIGITORUM BREVIS TECHNIQUEWhen contracted, the short toe fl exors in the sole of the foot (Image 8) contribute to hammertoes by curling the PIPJ and DIPJ, the two distal joints of the toe. The fl exors are found just deep to the plantar fascia,

in the most superfi cial muscle layer of the bottom of the foot.

Before attempting to work with this muscle layer, warm up the superfi cial and plantar fascia of the sole. These tissues can also contribute to toe fl exure. Use any broad, superfi cial technique for this preparatory work. (One example is the Plantar Fascia Technique described in “Working With Ankle Mobility, Part 1,” Massage & Bodywork, March/April 2011, page 113.) Avoid using oil or cream, at least at this point, since reducing friction makes it more diffi cult to work with the sole’s distinct tissue layers. Instead, slow down and let the tissues melt.

Once you’ve prepared the superfi cial and plantar fascia, use the tips of your curled thumbs to anchor the short, strong fl exors in a heelward direction, as your client lifts the toes in active toe extension (Image 9). You can also use passive toe extension, gently stretching the toes into extension with your free hand. This combination of anchoring into the short fl exors and adding movement is very effective in lengthening contracted or shortened lines of strain in the underside of the

Use active or passive client movement to lengthen contracted toe fl exors in the Flexor Digitorum Brevis Technique. Image 8 courtesy Advanced-Trainings.com. The short toe fl exors are shown in green. The long toe fl exors (red) will be discussed in the next installment. Image 9 courtesy Primal Pictures; used by permission.

The Extensor Digitorum Brevis Technique. By anchoring into the short toe extensors on the top of the foot, you may use active or passive toe fl exion to lengthen the short toe extensors. Image 12 shows the extensor digitorum brevis (green), as well as the extensor digitorum longus (red), covered in our next installment. Images 10 and 11 courtesy Advanced-Trainings.com; used with permission. Image 12 courtesy Primal Pictures; used by permission.

8

9

10

11

12

Celebrate ABMP’s 25th anniversary and you may win a refund on your membership. ABMP.com. 117

MyOFAscIAL TEchnIquEs

Til Luchau is a member of the Advanced-Trainings.com faculty, which

offers distance learning and in-person seminars throughout the united states

and abroad. he is also a certified Advanced Rolfer and has taught for the

Rolf Institute of structural Integration for 22 years. contact him via info@

advanced-trainings.com and Advanced-Trainings.com’s Facebook page.

foot. Be thorough, working the entire sole from toes to the origin of the flexors on the anterior calcaneus.

EXTENSOR DIGITORUM BREVIS TECHNIQUEThe extensor digitorum brevis (Image 12, page 115), the only muscle (along with its hallucis head) on the dorsal surface of the foot, complements the short toe flexors by pulling the MTPJ (the joint at the base of the toe) into extension or dorsiflexion. When tight, this up-bent dorsiflexion becomes the resting position of the toe joint. Use your fingertips, as in Images 10 and 11 (page 115), to release any contracted tissue here, this time using toe curling or flexion as active or passive client movements. Isolate each toe in turn, feeling for the specific head of the brevis that’s involved in that toe’s extension.

TOE TENDONS, CAPSULES, AND SHEATHSIt will be important to spend some time working slowly and deeply right around the joints of the toes themselves. Both the extensors (dorsally) and the flexors (on the plantar surface) merge with their longer counterparts (the flexor and extensor digitorum longus) into tendinous hoods within the toe (Image 13). In a hammertoe pattern, these fibrous sheaths become contracted on the concave sides of the joint (in the crease of the bent toe, Image 7).

The joint capsules are also involved in maintaining a bent joint, as are the collateral ligaments of the toes, found at the sides of all three toe joints. They are largest and strongest at the MTPJ, lying between the base of the toes. These ligaments, and other structures between the long metatarsals of the foot, such as the adductors and lumbricals, will need to be gently lengthened before normal alignment is possible. As with our other

techniques, use active and passive client movement, along with your direct pressure, to lengthen these shortened tissues.

If your client has already had hammertoe surgery, working the ligaments and tissues of toes can help reduce pain once the surgery has healed (after at least 6–8 weeks).

Although the toes and their ligaments are painful, sensitive, or ticklish on many people, if you take your time and stay in close communication with your client, the sensation will be well tolerated. The normalization of hypersensitive areas can itself be very therapeutic. Combined with the tissue changes from your work, it will yield gratifying changes in flexibility and pain reduction. At this point, you’ve worked the short toe flexors and extensors, as well as the capsules, ligaments, and sheaths of the toe joints themselves. Although there is more to do, and you may need repeated visits to see a visible change in the resting position of the toes, in many cases, your client will already notice greater toe flexibility and comfort.

Be sure to have a look at the next column, where I’ll talk about the long toe flexors and extensors and the role of the lower leg in toe deformities, as well as the whole-body implications of hammertoes, bunions, and more.

Notes 1. Remedy health Communities, “hammer

toe Remedies,” accessed april 2011, www.

healthcommunities.com/hammertoesclaw-

toes/hammertoe-remedies.shtml.

2 anthony watson, “hammertoe deformity,”

accessed april 2012, http://emedicine.

medscape.com/article/1235341-overview.

3 w. Fishco, “emerging Concepts in

hammertoe surgery,” Podiatry Today 22, no.

9 (september 2009): 34–9. accessed april

2011, www.podiatrytoday.com/emerging-

concepts-in-hammertoe-surgery.

13The flexor tendon sheaths (orange) are some of the fibrous connective tissue structures that surround the toe joints. They can contribute to toe-joint fixation. Work these structures combining pressure with active and passive movement. Image courtesy Primal Pictures; used by permission.