In forefoot pain, the lateral 2 to 5 toes, and the corresponding metatarsophalangeal joint or submetatarsal head pain, are the most problematic conditions for clinicians. After performing a detailed examination and test, the diagnosis is usually not difficult to confirm and treatment is relatively uncomplicated. However, forefoot pain is usually diagnosed and treated by a foot and ankle surgeon, and may require special care in identification by a general orthopedic surgeon because of an incomplete understanding of this area. This article provides a brief explanation of the most common hammer toe of the forefoot. Hammer toe is a common deformity of the toes, defined as a state of deformity in which the metatarsophalangeal joint is hyperextended, the proximal interphalangeal joint is flexed, and the distal interphalangeal joint is straightened. The deformity is usually seen in the 2nd and 3rd toes and is usually differentiated from hammer toe by claw toe and mallet toe. Severe deformities can be complicated by dorsal corns on the interphalangeal joint or severe painful calluses at the tip of the toe. When the deformity is present, the patient is severely restricted in wearing shoes, sometimes even loose athletic shoes. Walking becomes an ordeal and the long-term deformity can cause severe functional limitations of the patient’s foot. The main objective of the examination is to distinguish whether the deformity is flexible or rigid. Stiff deformities usually require interphalangeal arthroplasty (DuVries procedure), while flexible deformities can usually be treated with tendon transposition. It is then important to note whether the deformity is located in the metatarsophalangeal joint or the proximal interphalangeal joint, or both. The drawer test (Lachman’s test), the drawer test examines the function of the metatarsal plate and lateral collateral ligaments. It is usually considered positive when there is a dorsiflexion shift of more than 2 mm or a shift of more than 50% of the distal toe. It is important that the examiner’s hand is in the correct position, as this may result in a false positive result. Etiology There are three main causes of hammertoe formation: bunion, overgrowth of the second metatarsal, and wearing pointed shoes. In these three conditions, the toe is subjected to abnormal stress over time and gradually develops a deformity. Clinically, you may also see patients with a short 1st metatarsal who develop a hammertoe because of excessive stress on the lateral metatarsals. The presence of a hammertoe is usually followed by an imbalance in muscle strength and instability of the metatarsophalangeal joint in the foot. Decreased muscle strength in the intrinsic muscles of the foot can result in inadequate flexion strength of the metatarsophalangeal joint and inadequate dorsiflexion strength of the interphalangeal joint. As a result, the long and short toe extensor tendons and the long and short toe flexor tendons are relatively overpowered and a hammertoe deformity occurs. Muscle strength imbalance and long term deformity of the toe can result in loss of interphalangeal joint mobility, from a pliable deformity, to a stiff deformity. In addition, deformed toes cause damage, malfunction, or fracture to the stable structures of the metatarsophalangeal joint, such as the collateral ligaments and metatarsal plates, which are subjected to excessive stress during foot walking. This results in crossed toes or “floating toes”. In terms of precise definition, the mechanism of damage to the toe in a metatarsal plate injury is not exactly the same as in a bunion. However, the result of long-term stress is essentially the same. Clinically speaking, the treatment of these deformities is also the same and is discussed here together (Figure 2). The deformity is usually seen in the 2nd and 3rd toes (Figure 3). The usual stabilizing structures of the toe are the metatarsal plate and the lateral collateral ligaments of the metatarsophalangeal joint. Collateral ligament injuries can cause instability of the toe in the coronal plane, while metatarsal plate injuries cause instability in the sagittal plane. If both are present, a crossed toe may be present. Treatment There are not many treatment options for hammertoe. Conservative treatment requires a crescent-shaped toe pad under the toe to accommodate the deformity if it is a stiff deformity, or a hammertoe pad to limit it if it is a flexible deformity. However, the long-term results of conservative treatment are not good. The patient’s pain will reappear after a period of treatment. The surgical options for lateral toe deformities are more limited. The usual methods used are the Weil osteotomy (metatarsal head shortening osteotomy), the Girdlestone-Taylor procedure (flexor tendon to extensor tendon transposition), and the Z-lengthening of the extensor tendon. In case of rigid deformity, arthroplasty (DuVries procedure) can be performed at the interphalangeal joint. Treatment of claw toe is similar to hammertoe, but stiff claw toe is more dependent on shortening of the metatarsal osteotomy or soft tissue release. All of these treatments have complications, such as recurrence of toe deformity, toe stiffness, toe weakness, or residual pain, but the incidence varies. The most common unsatisfactory outcome for patients is stiffness. Abnormal toe muscle strength cannot be fully restored by surgery, so it is important to communicate with the patient before surgery that the purpose of the surgery is to relieve pain and wear shoes, and that the patient understands the purpose of the surgery before proceeding. If the patient has high expectations, it is not suitable for surgical management. In patients with metatarsal plate injuries, “floating toe” is the most common postoperative complication, and this complication may be related to the lack of metatarsal plate repair. Recent articles have reported that surgical repair of the metatarsal plate, or metatarsophalangeal capsular repair, can address this problem, as detailed in the literature.