Scenario: Patient is a 25-year-old soccer player. For fun he was kicking the ball around barefoot and stubbed his toes into the ground when trying to kick the ball. The patient had immediate pain and x-rays were negative for fractures. He presents to the clinic with the third toe bent with flexion of proximal interphalangeal (PIP) and DIP joints. The patient has swelling and cannot wear a closed toe shoe.

Question: Once swelling has been addressed, what joint mobilizations should be prioritized, and why?

Potential answers:

1. MTP joint of the affected toe. Dorsal/plantar and medial/lateral glides.
2. Tarsometatarsal joint. Dorsal/plantar glides.
3. MTP, PIP, and DIP joints of the affected toe. Dorsal/plantar and medial/lateral glides and rotation.
4. DIP joint of the affected toe. Dorsal/plantar glides and rotation.

Answer with rationale: MTP, PIP, and DIP joints of the affected toe. Dorsal/plantar and medial/lateral glides and rotation.

The metatarsophalangeal (MTP) joint will have decreased mobilization, and may be completely immobilized in hyperextension. There may also be a callus present at the plantar aspect of the MTP joint causing increased alteration of the biomechanics of the joint and increased extension.

The proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the toe are immobilized in flexion in part due to inflammation. Other causes for this contracture include shortened flexor muscles and fascia, altered joint positioning and arthrokinematics, and poorly fitted footwear.

Joint mobilizations such as glides and rotations will assist with recovering mobility as well as proper biomechanics at the joints involved. These mobilizations can also help with pain modulation and limiting continued inflammation and contractures.

Overall treatment of hammer toe should also include initial rest, cryotherapy and pain modulation followed by orthotics prescription, strengthening exercises, stretching, soft tissue mobilization, and patient education on footwear.

^{Multiple hammertoes, hallux flexus, onychauxis, residual of rheumatoid arthritis, and degenerative changes. (From Halter JB et al: Hazzardís Geriatric Medicine and Gerontology, 6th edition. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.}

For more information see chapter 210 Hammer Toe in the Color Atlas of Physical Therapy