The recent interest in shoe inserts in the retail community has caused an explosion of store chains and individual businesses that have begun to offer these devices to the general public. Unfortunately, very few of these retail stores or businesses have employees, managers, or even owners who have any clear idea how the foot actually functions, and certainly do not have medical or biomechanical training appropriate to make claims on how an insert is going to affect a foot. As such, this author (a practicing foot and ankle surgeon) has heard numerous and dubious claims as to the effectiveness of insert ‘x’ versus insert ‘y’. One of the more common and dubious misrepresentations seen is that of the effectiveness of a shoe insert to control or cure hammertoe deformity. This article will discuss that deformity, as well as how inserts actually effect the development or progression of hammertoes versus the claims of some shoe insert retailers.
Hammertoes are common in humans, and simply represent an imbalance of the muscles that control the flexing and extending of the toes. There are several conditions that can lead to this deformity, but by far and away the usual cause is one’s genetic foot structure from birth. The most common cause of hammertoes is a flat foot structure, followed by a high arch foot structure as the next most common cause. Although these foot shapes are on the far end of the spectrum from one another, they exert somewhat similar effects on the toes. Essentially, the leg muscle adjustments that have to be made to stabilize a flat foot, or accommodate for a more rigid high arch, causes an imbalance in a complex coordination of moving tissue in the foot. The eventual result over a long period of time is the gradual drawing up or curling of the toes. Although medically the word ‘hammertoe’ describes a specific type of toe joint contracture, it is commonly used in public to describe all types of toe bending (including claw toes and mallet toes). For the sake of simplicity in this article the term hammertoes will likewise represent all these types.
The formation of hammertoes is a long process that occurs over decades, starting with one’s first steps. Some children develop these quickly due to advanced changes in the structural imbalance (or due to neuromuscular birth defects), while others do not see notable changes until well into adulthood. Regardless of the timing, one thing is clear: no pad, brace, taping technique, or shoe insert will alter or change the toe structure once the deformity occurs. Nothing.
Herein lies the problems with the claims of some retail insert stores. An off-the-shelf insert will have no effect whatsoever on one’s hammertoes. In fact, if the device fits poorly in the shoe, it can actually worsen the hammertoe’s symptoms by forcing the toes to become too prominent against the top of the shoe. A hammertoe is already at risk for developing corns due to excessive pressure against the top of shoe, and any excessively bulky or abnormally fitting shoe insert that has an extension to the toes can make this worse. The only way to ‘fix’ a hammertoe is to have a surgical corrective procedure performed upon it. This procedure can be as simple as releasing a tendon in an office setting, or as complex as a bone fusion procedure that reshapes the toe into a straight lever. Most hammertoe corrective surgery falls somewhere in between, with some tissue rebalancing and some bone reshaping to allow the toe to settle into a straight position. Recovery is relatively easy, and has a low complication rate. Other than surgery, no other technique will bring a hammertoe into a permanently straight position. Pads will relieve skin pressure, taping and splints will temporarily hold the toe down while they are applied, and inserts will do….well, nothing. An exception is the use of a prescription insert made of a mold of one’s foot while that foot is held in a very specific anatomic neutral position. This type of medical device is called a functional orthotic (as opposed to store-bought inserts that are accommodative orthotics as they simply accommodate the foot without correcting it). This prescription devise likewise will not correct a hammertoe deformity, as once again only surgery will do. However, a functional orthotic will decrease the potential worsening a hammertoe will undergo over the course of many years by helping to correct the abnormal tissue imbalance seen in those with flat feet. In these individuals, a prescription insert may keep the hammertoe from becoming significantly worse if used regularly for years. This is a benefit that a store-bought insert will not provide, no matter how much they cost, though the benefit is of little help for those with existing hammertoes that are painful.
In summary, it should be clear by this point that shoe inserts will not help ‘cure’ hammertoes or hammertoe pain. Even a prescription insert is of little help, except to change the underlying foot structure to slow down gradual worsening of the deformity. Spending large sums of money on factory-made plastic devices will solve nothing except to lighten the wallet. Hammertoes need an evaluation by a physician foot specialist with years of medical, biomechanical, and surgical training to determine the best treatment course, and not the opinion of a retail sales clerk. One does not go to the department store cosmetics counter for an opinion on skin cancer, and neither should one rely on a shoe or insert retail store for an opinion on a foot deformity.