Patients presenting with a bunion often have an additional concern: one or more of the smaller toes have started to curl, cross, or ride up in a way that was not there before. This is not a coincidence. Hammertoes and bunions can be mechanically related, and in some patients the progression of one deformity can contribute to the other.
Understanding the relationship between these two deformities changes how patients approach treatment. It also shapes the surgical conversation, because addressing a bunion without accounting for existing hammertoe involvement, or vice versa, can leave part of the problem untreated. This blog by Christopher Sakowski, MD, covers the mechanical connection between the two conditions, how each progresses over time when left alone, what conservative care can realistically offer, and when a single corrective procedure makes sense.
What Each Deformity Involves
Bunions
A bunion, or hallux valgus, is a progressive deformity of the first metatarsophalangeal joint, the joint at the base of the big toe. As the condition develops, the big toe drifts toward the lesser toes while the metatarsal head shifts outward, creating the visible bony prominence along the inside of the foot. The underlying problem is a loss of alignment in the joint, which then becomes self-reinforcing as the tendons and soft tissues adapt to the abnormal position.
Because the big toe is the primary stabilizing digit for the forefoot, any significant change in its position affects the mechanical environment of every toe beside it.
Hammertoes
A hammertoe is a contracture deformity of one or more of the lesser toes, most often the second, third, or fourth. The affected toe bends abnormally at the proximal interphalangeal joint, the middle joint of the toe, and in many cases at the metatarsophalangeal joint as well. Depending on the degree and duration of the deformity, a hammertoe may be flexible, meaning it can still be manually straightened, or rigid, meaning the contracture has become fixed and the joint can no longer be passively reduced.
The bent position causes the prominent knuckle of the toe to rub against the top of the shoe, producing corns, calluses, and in more advanced cases, painful ulcerations. The tip of the toe may also press into the ground or into adjacent toes, adding to the overall burden of symptoms.
The Anatomical Relationship Between Bunions and Hammertoes
The connection between these two conditions is mechanical, and it operates in a specific direction. A drifting big toe does not simply move in isolation. As hallux valgus progresses, the big toe rotates and shifts toward the second toe, progressively encroaching on the space that the second toe normally occupies. Depending on the degree of drift, the big toe may eventually underlap or overlap the second toe entirely.
As the second toe is displaced by the advancing big toe, several things happen simultaneously. The second metatarsophalangeal joint, which connects the second toe to the forefoot, is subjected to abnormal loading forces. The tendons that normally hold the second toe in a straight, neutral position are placed under imbalanced tension. The toe begins to buckle at its middle joint in response to the mechanical disruption.
This process repeats with the third and sometimes fourth toes as the crowding effect cascades across the forefoot. Each toe displaced by the one beside it is pushed into an environment where normal tendon balance is disrupted, and the contracture deformity that follows is the predictable result.
The metatarsophalangeal joint of the second toe deserves particular attention in this relationship. When a bunion causes prolonged abnormal loading at this joint, the plantar plate, a thick fibrous structure on the underside of the joint that stabilizes the toe from below, can stretch and eventually tear. A damaged plantar plate allows the toe to drift upward at the metatarsophalangeal joint while it buckles at the proximal interphalangeal joint, producing what is sometimes called a crossover toe deformity in more advanced cases. This level of involvement is a direct downstream consequence of uncorrected hallux valgus.
How These Deformities Progress When Left Untreated
Bunions and hammertoes are structural deformities that generally do not correct themselves without surgery. Their symptoms and degree of progression can vary considerably between patients.
Bunion Progression
In the early stages, a bunion may cause only mild discomfort or be noticed primarily as a cosmetic change. The intermetatarsal angle, the angle between the first and second metatarsal bones, is still relatively modest, and the big toe has not yet significantly encroached on the second toe’s space. Conservative management can often control symptoms effectively at this stage.
Over years, the angular drift increases. The bony prominence becomes more pronounced, the surrounding bursa thickens and inflames with increasing regularity, and the big toe’s effect on the lesser toes intensifies. The joint itself begins to deteriorate as chronic malalignment produces wear on the articular cartilage. By the time a patient presents with a severe bunion, the first metatarsophalangeal joint may have significant degenerative changes, and the lesser toes may already show established contracture deformities as a result of the long-term crowding.
Hammertoe Progression
Hammertoes follow their own progression from flexible to rigid. In the flexible stage, the toe can still be passively straightened, meaning the contracture involves soft tissue imbalance but the joint itself retains its range of motion. Conservative measures are most effective at this stage. If the deformity is not addressed, the soft tissue imbalance persists, the toe spends increasing amounts of time in the bent position, and the joint gradually loses its capacity for passive correction.
Once a hammertoe becomes rigid, the joint capsule and surrounding structures have adapted fully to the abnormal position, and manual reduction is no longer possible. A rigid hammertoe is more symptomatic than a flexible one, harder to accommodate in footwear, and requires more extensive surgical correction when operative treatment is eventually pursued.
The combination of an advancing bunion and progressively rigid hammertoes creates a situation where foot function deteriorates on multiple fronts simultaneously. Gait mechanics are altered, shoe fitting becomes increasingly difficult, and the risk of skin breakdown and secondary infection rises, particularly in older patients or those with diabetes or peripheral vascular disease.
The Order in Which Conservative Options Are Considered
For both conditions, conservative management is the appropriate starting point whenever symptoms can be reasonably controlled without surgery. The goals of conservative care are symptom management and slowing of progression, not structural correction, which remains the domain of surgery.
Footwear
The most impactful conservative intervention for both hammertoes and bunions is choosing footwear with adequate toe box width, low heel height, and soft upper material that does not compress or rub against prominent deformities. A wide, rounded toe box reduces the external pressure that accelerates crowding of the lesser toes and irritates both the bunion prominence and the hammer toe knuckle. This single change, made consistently, has a meaningful effect on day-to-day comfort and the rate at which deformities progress.
Padding and Splinting
Silicone toe separators placed between the big and second toe can provide cushioning and temporarily reduce the lateral pressure of the bunion on the lesser toes. Hammertoe pads placed over the prominent knuckle reduce friction against the shoe’s upper. Toe loops or sleeves can hold a flexible hammertoe in a more corrected position during activity. These are symptom management tools rather than corrective devices, but they allow many patients to remain comfortable through extended periods without surgery.
Orthotics
Custom or prefabricated orthotics can address the mechanical contributors to both conditions. For patients whose bunion and hammertoe development is associated with flatfoot or excessive pronation, an orthotic that provides medial arch support and reduces inward rolling of the foot during the gait cycle can relieve some of the abnormal loading on the first metatarsophalangeal joint and the lesser toe joints. Orthotics are most effective as part of a broader management approach rather than as a standalone solution.
Activity Modification
Reducing high-impact activities and prolonged standing during periods of acute irritation can provide relief without eliminating function. Patients who have physically demanding occupations or recreational activities that consistently aggravate their symptoms may benefit from alternating footwear types throughout the day or substituting lower-impact activities during flare-up periods.
The American Academy of Orthopaedic Surgeons notes that conservative measures for both bunions and hammertoes focus on relieving symptoms and slowing progression, and that structural correction requires surgery. This distinction matters when patients are deciding how long to pursue non-operative care.
When Both Conditions Can Be Corrected in a Single Operation
One of the most practical advantages of treating hammertoes and bunions together is that both are forefoot problems accessible in a single operative setting. When both deformities are present and symptomatic, staging the procedures separately, meaning correcting the bunion first and returning later for the hammertoes, requires two anesthetic events, two recovery periods, and a longer overall period of functional limitation.
Addressing both in one operation avoids that duplication when the patient’s overall health permits it, and the deformities are appropriate for combined correction. There are also mechanical reasons to treat them together. Correcting the bunion changes the spatial environment of the lesser toes. If a hammertoe is caused or significantly worsened by the crowding from the bunion, correcting the bunion alone may partially relieve the hammertoe. But if the hammertoe has progressed to the point of rigidity or significant plantar plate involvement, it is unlikely to self-correct and requires direct treatment regardless of what happens to the bunion.
The decision about whether to combine procedures is made based on the specific anatomy of each case. Relevant factors include:
- The severity and rigidity of each hammertoe
- Whether plantar plate injury is contributing to any of the lesser toe deformities
- The degree of the bunion correction required and whether the lesser toes are likely to improve with bunion correction alone
- The patient’s overall health and tolerance for a combined procedure
- The patient’s recovery goals and lifestyle demands
An evaluation with a foot bunion specialist who routinely manages both conditions is the most reliable way to determine what the right surgical plan looks like for a given patient. The goal is a single, well-planned correction that addresses the full extent of the deformity rather than a piecemeal approach that leaves part of the problem behind.
When to Seek an Evaluation
Patients with a bunion should pay attention to what is happening with the lesser toes at the same time. The two conditions are not independent, and changes in the lesser toes can serve as a useful indicator of how the bunion is progressing.
An evaluation is worth pursuing sooner rather than later when any of the following are present:
- A second toe that is beginning to rise above or cross over the big toe
- Painful corns or calluses on the tops or tips of the lesser toes that are not relieved by padding or footwear changes
- A toe that was previously flexible and can no longer be straightened
- Increasing difficulty fitting into standard shoes without significant pressure on the forefoot
- Pain at the ball of the foot beneath the second or third metatarsal head, which may indicate plantar plate involvement
- Any skin breakdown or ulceration over a prominent bony deformity
The window for the most conservative surgical approaches narrows as deformities become more rigid and as secondary joint damage accumulates. Patients who are evaluated earlier in the process generally have more options available and tend to have simpler corrections with more predictable outcomes.
Frequently Asked Questions
Can a bunion cause hammertoes to develop?
Yes. As the big toe drifts toward the lesser toes in hallux valgus, it displaces the second toe and disrupts the normal tendon balance that keeps the lesser toes straight. This mechanical crowding and imbalance is one of the primary drivers of hammertoe formation in patients with bunions. The two conditions frequently develop together for this reason.
Can hammertoes be corrected without surgery?
Conservative measures including footwear modifications, padding, splinting, and orthotics can relieve symptoms and slow the progression of flexible hammertoes. They do not correct the underlying structural deformity. Once a hammertoe becomes rigid, the joint cannot be passively straightened, and surgical correction is the only way to address the deformity itself. This is why earlier intervention, before rigidity develops, preserves more treatment options.
If my bunion is corrected, will my hammertoe improve on its own?
It depends on the stage of the hammertoe. If the lesser toe deformity is mild and primarily driven by crowding from the bunion, correcting the bunion may relieve enough of the mechanical pressure to allow improvement. If the hammertoe is already rigid or involves plantar plate injury, it is unlikely to self-correct after bunion surgery and should be addressed directly. Your surgeon will evaluate each toe individually before making a recommendation.
Is combined hammertoe and bunion surgery more difficult to recover from?
A combined procedure addresses more of the foot at once, which can mean more overall swelling and a recovery that involves the entire forefoot rather than a single area. However, it also means a single recovery period rather than two, which most patients prefer when both conditions require treatment. The recovery protocols and timeline are discussed in detail before surgery so patients can plan appropriately.
At what point does a hammertoe become a surgical problem?
A hammertoe typically becomes a surgical problem when it has progressed to the point where footwear accommodation is no longer adequate, conservative symptom management is failing, the toe has become rigid and cannot be manually corrected, or skin breakdown is occurring over the prominent joint. The earlier stage, when the toe is still flexible, generally allows for less invasive surgical correction than a fully rigid deformity.
Can both conditions come back after surgery?
Recurrence of either bunion or hammertoe deformity is a known risk with any corrective surgery. The likelihood depends on the severity of the original deformity, the specific techniques used, bone quality, and post-operative footwear habits. Wearing appropriate footwear after surgery and following post-operative guidance helps reduce the risk, but no surgical correction eliminates it entirely. Your surgeon will discuss recurrence risk specific to your case.
Two Conditions, One Conversation
Hammertoes and bunions are not separate problems that happen to appear on the same foot. They are mechanically connected conditions that develop along a shared pathway, influence each other’s progression, and in many cases need to be treated together to achieve a lasting result.
At Dallas Orthopedic Foot and Ankle Surgeons, Dr. Christopher Sakowski evaluates the full forefoot when patients present with either condition. If you are managing a bunion with or without lesser toe involvement and want to understand where your deformity stands and what your options are, contact our office to schedule an evaluation.
Written By Dr. Christopher Sakowski, MD
Dr. Christopher Sakowski is a board-certified orthopedic foot and ankle specialist based in Dallas and Plano, Texas. He completed his fellowship training at the Institute for Foot and Ankle Reconstruction at Mercy Hospital in Baltimore and has been recognized as a Best Doctor in Dallas and Collin County every year from 2020 through 2026. His practice, Dallas Orthopedic Foot and Ankle Surgeons, is focused exclusively on the diagnosis, treatment, and surgical management of foot and ankle conditions for patients throughout the Dallas metroplex.