By now you may have heard that Barbara Bush (91) has only four toes on each foot. Her granddaughter, Jenna Bush Hager, informed the nation of this fact during a talk show.

Jenna originally thought the toes “fell off” due to “age” or worse, lack of sleep - which certainly peaked my interest. No one ever told me I might spontaneously lose toes at a certain age. My older friends and relatives have contained their body part losses to teeth, at least so far.

The next day, Jenna (presumably after a little fact gathering) informed the nation that the elder Ms. Bush had toes (it is believed the second toes) removed due to overcrowding.

Now I will caution you from making any rash judgments - there may very well be some other health information held back (that is none of our business anyway) that could be relevant to her case. I presume no one has toes removed due to overcrowding unless there are justifiable complications. It isn’t something one does for “convenience” (e.g., to fit into a narrow or pointed shoe).

It was a relief to find out that Ms. Bush’s toes were amputated on purpose and didn’t just fall off, but there is a condition where toes can “self amputate” from dry gangrene, which arises from circulatory problems.

A quick internet search led to a great many reasons why someone might get dry gangrene, some of which include:

  • cancer (Warfarin related)
  • deep vein thrombosis (DVT)
  • staphylococcus infection
  • severe secondary Raynaud’s
  • renal disease
  • diabetes
  • dengue fever
  • stingray injury (really)

Since this is a movement blog, and not a medical one, I will leave these serious conditions to the experts.

Let’s focus instead on the mechanical reasons one could have hammertoes, serious crowding in the toes, lack of circulation in the toes, and malpositioned toes.

Perhaps a little education and a lot of movement homework can reverse some of this damage!


You can start to build a stronger, healthier foot with a Free Sneak Peak of the Healthy Moving for Bunions Workshop! Register here to learn two of the exercises included in this Deep Dive Course.

The common factor in the above list is lack of circulation. If you are experiencing sensations of paresthesia[1] I would encourage you to visit your health professional to rule out anything serious, particularly if you have any known health complications.

However, if you just have hammertoes or deviated (sideways) toes, read on!

What are hammertoes?

Hammertoes can occur in the second (most frequently), third, fourth and fifth toes. It refers specifically to the joint in the middle of the toes - there are two joints in the toes, named for their bones; these are the inter-phalangeal joints (between the phalangeal bones). The one closest to the foot is called the Proximal (closest) Inter-Phalangeal joint (PIP) and the one closest to the nail is called the Distal (farthest) Inter-Phalangeal joint (DIP).

So these are referred to adorably as your PIPs and DIPs.

Hammertoes are an abnormal bend at the PIP, and Mallet toes are an abnormal bend at the DIP.[2]

Ill fitting shoes are the leading cause of these deformities! Neuromuscular anomalies are also implicated. The first thing is pretty easy to rectify, the second, not so much (but not impossible).

Hammertoes and mallet toes are an acquired deformity that are correctable but it’s important to start as soon as you notice them; in the early stages while the foot is still flexible. Later, the tendons and ligaments can become contracted and more rigid.

The most common toe to be affected is the second toe, especially if it is the longest one. If you have a second toe that is the longest toe, it will hit the end of your shoe as you walk and be pushed back.

Take special care to find a shoe that is wide and long enough for all of your toes! Narrow toed, or pointy shoes in particular are to be avoided as they squeeze the toes together, leading to overcrowding and lack of circulation.

Shoes with a heel will cause the foot to stand downhill all the time, and there are two reasons why this can result in hammertoes/mallet toes (and claw toes):

  1. This pushes the toes into the front of the shoe even more.
  2. The pressure is predominantly on the ball of the foot, with the toes pointing up relative to the rest of the foot. The higher the heel, the more extended the toe at the joint where the toe attaches to the foot (the metatarsal-phalangeal joint - or MP joint). This shortens the tendons of the top of the foot and stretches those on the bottom.

The relationship of these bones to each other determines the effect that the muscles and tendons have on the joints. If the MP joint is in a neutral position, the pull of the extensor digitorum longus can extend (straighten) the PIP, but if the MP joint is extended, the action of the extensor digitorum longus changes, and can flex (bend) the PIP.

What this means is that the muscle can actually change its leverage to make the condition worse if you wear high heels (or just heels in general - try to find shoes that have no positive heel at all).

The plantar fascia, which is a connective tissue structure on the bottom of the foot helps to stabilize the ball of the foot against the extreme pulling of the tendons on the top of the foot. The health of this tissue is thus integral in keeping the toe straight (particularly the first bone of the toe, which is extended (dorsiflexed or lifted) in the case of the hammertoe.

Let’s recap:

  • Hammertoes are acquired - you get them mostly by wearing ill fitting shoes.
  • Shoes with a heel and/or a narrow toe box are implicated in hammertoes and other toe deformities.
  • The muscles of the foot and leg that move the toes can make the condition worse if your bones aren’t in the right place.
  • If you have bones that aren’t in the right place, they can start affecting other structures in the foot.
  • The condition is more difficult to correct the longer you have it.

The first line of defense is to change your shoe choice. This might seem easy but your feet might need some time to adapt to a radically (for them) different shoe, especially if you are used to a heel, to go to no heel can be injurious without proper preparation.

The second line of defense is to start working the foot muscles, bones and joints in ways that will eventually lead to straighter toes and less crowding.

To that end, I like to use devices that help the toes spread out. There are toe spacers and socks to wear that keep the toes separated - again, take care not to go too fast too soon with these devices. Wear them a short time every day and do the exercises.

Circulation to the muscles, tissues and cells of the feet depend on the feet being able to move in all the ways they were meant to, with adequate space for the foot and toes to spread in all directions and not be restricted by tight shoes.

Not only do the feet need the space for movement, but they need to actually do the movement.

Some ideas to increase circulation to foot tissues that have not had adequate usage till the present:

  1. Walk barefoot if you can, around the house and garden.
  2. Make a rock box (you can fill a boot tray with river rock) and stand in it when you do your kitchen work.
  3. Get a massage ball like a Yoga Tune Up®, tennis ball or Pinkie ball and roll your feet, move them over the ball when you are sitting at the table or desk. (Just because you are still does not mean your feet have to be!)
  4. Practice some foot exercises. (My Healthy Moving for Bunions Workshop is a great place to start, even if you don’t have bunions! You can get a free sneak preview of that course here.)
  5. Wear toe spacers when you can, or socks separators around the house, or when you watch TV.
  6. Try to walk on natural surfaces when you get the chance (i.e., lawns instead of sidewalks, off the path in the park or forest - don’t avoid the tree roots and pinecones).
  7. Try to pick up objects with your toes, or try to write your name or color with your feet. (You can have fun with your kids or grandkids and make a game out of this!)
  8. Practice lifting your toes one at a time or lifting them all and putting them down one at a time (like doing piano scales).
  9. Walk more! (And probably run less - if you are a runner, try replacing some of your running with walking.)
  10. Try to vary your walking routes to include hills.

As always, proceed with care and common sense and you should be on track to keep all your toes for life.

Carol Robbins honed her eye for movement by watching and riding dressage horses for most of her life. In her late 30s she started teaching movement to people, first as a Pilates teacher and now as a Nutritious Movement™ certified Restorative Exercise Specialist. She is a teacher trainer for the Nutritious Movement™ organization, teaching students all over the world by Skype and in person at the Centre in Washington State. Based in Toronto she runs a private studio called The Alignment REScue where she works with people one-on- one and in groups. She holds workshops in various Toronto area studios on a variety of subjects but her favorite topics are Feet and Shoulders!

Her own feet have been her greatest teachers – inspiring an ongoing interest in anatomy and carrying her far and wide across this great planet for 56 years despite several challenging features, including bunions!

She is the instructor of the Healthy Moving for Bunions Workshop.

[1] Paresthesia is an abnormal condition in which you feel a sensation of burning, numbness, tingling, itching or prickling. Paresthesia can also be described as a pins-and-needles or skin-crawling sensation.


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This article has 4 comments

  1. Barbara Hanna Reply

    I think you are wrong that hammer toes are necessarily acquired. I think they may be inherited. My mother, my sister, my niece and I have all had hammertoes. None of us have worn pinched or narrow high heels in our life.

    • Carol Robbins Reply

      Hi Barbara, it will be difficult to reply to your comment without writing another blog post but I’ll try to keep it short. What is genetically inherited is the shape of your bones. For example, my feet look just like my father’s. But pathologies of the feet are from forces. So for example, none of you were probably born with hammertoes (just as I wasn’t born with bunions), but as you grew, you developed them. (Note: some babies are born with defects that are crooked toes and that can be inherited, and are usually corrected with casts when the baby is growing. This blog is about the kind that develops as you grow!)

      Our gait patterns are learned, much as an accent is when you are learning to talk. The other thing that is passed down is shoe choice – our parents usually being the first person to make the choice as to what we put on our feet at around age 1 up to the age when we decide what shoes to buy. Although you may not have worn very high or very pointy shoes, the fact remains that almost all shoes on the market are narrower than our feet are – all of them! There are only a handful of companies that make shoes with a toe box wider than the ball of the foot. So maybe my post was a bit misleading in suggesting such a radical shoe was to blame, when in fact, almost all shoes are to blame. Also, although a 2 or 3″ heel might not be common for all of us (I’m over six feet tall and I NEVER wore “heels”), ALL shoes have what is called a “positive” heel – meaning the heel of the foot is higher than the ball (even running shoes have positive heels). So it only takes the predisposition in terms of bone shapes (longer second toe was the example I gave), gait patterns and the wearing of typical shoes to start the process (forces) that create the pathology.

      Another thing to consider – and one I didn’t add to the post above – is that flip flops, which are certainly minimal and have NO heel (good) also create hammertoes! This is because the toes have to grip them when you are walking. It’s best if you are going to wear them to find ones that have a heel strap. Thanks for your comment and the discussion!

  2. Leah Reply

    I have very curled toes though I’m not necessarily sure they are hammer toes. The nail on my 3.4.5th toes all point forward while the tip of my toe is what makes contact with the ground. I can stretch all but my 5th toe to be flat but they relax into a curled position. I did not wear shoes until I was 5 and I have always worn generally foot healthy shoes. I have noticed that I grip with my feet as a stress response. I do think there is a genetic component. My mom was a very committed barefooter and has similarly shaped toes. I hope that I can get them to a more uncurled state.

    • Carol Robbins Reply

      Hi Leah, That is a bend at the DIP joint and is usually termed “mallet” toe. There is a muscle called “Flexor Digitorum Longus” that attaches to the very end of toes 2,3,4,5. This muscle runs under the foot and behind the inside ankle bone and up the lower leg where it attaches to the larger bone of the lower leg (tibia). It’s under the calf muscle. If the muscle is too tight, it will pull the ends of the toe bones down. I encourage you to look up a picture of that muscle to see if this makes sense, and I commend you for trying to get them straight! (And kudos to your mother for being a barefooter and making such good choices for you!)
      If you are a member of Jen’s community here, the Calf Stretch is a good exercise – along with intrinsic foot strengthening exercises. Good luck!

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