Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Hammertoe


Medical Codes

ICD-9-CM:
735.4 - Other Hammer Toe, Acquired

Related Terms

  • Claw Toe
  • Hammer Digit Syndrome
  • Hammertoe Deformity

Overview

© Reed Group
A hammertoe is a crooked (contracted) toe deformity in which the toe bends downward like a claw. It is most common in the second toe but may affect the second through fifth toes (lesser toes).

Hammertoe results from a buckling (contracture) of the middle joint of the toe (proximal interphalangeal joint, or PIP joint) that causes bending (flexion) of the toe (Schrier 194). As the deformity progresses, there may also be upward bending (hyperextension) of the first toe joint (metatarsophalangeal joint, or MTP joint) and the last joint (distal interphalangeal joint, or DIP joint) (Watson). Pressure points form on the bottom of the ball of the foot (metatarsal head) and on the top of the middle joint of the toe.

If only the DIP joint of the toe bends down, the deformity is known as a "mallet toe." If both the PIP joint and DIP joint bend down while the first joint (MTP joint) bends up, the condition is known as a "claw toe" (Watson).

A hammertoe can overlap or underlap another toe. Friction between a hammertoe and another toe or between two hammertoes can cause the toe bones to enlarge and a spur (exostosis) to form. A painful corn may form over the spur. Hammertoe may be painful due to pressure from shoes, from corns, or from arthritis, which often develops in the contracted joint.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report painful calluses on the top of the toe and under the metatarsal head (ball of the foot) of the corresponding toe. Individuals may also report pain in the toe joints, difficulty or pain when moving the toe, toe crookedness, and pain and pressure from shoes. They may also describe the sensation of a lump in the sole (plantar) side of the metatarsophalangeal joint.

Physical exam: The exam may reveal a toe in which the near bone of the toe (proximal phalanx) is angled upward and the middle bone of the toe points in the opposite direction (plantar flexed). Toes may appear crooked or rotated. The involved joint may be painful when moved, or stiff. There may be areas of thickened skin (corns or calluses) on top of or between the toes; a callus may also be observed at the tip of the affected toe beneath the toenail. An attempt to passively correct the deformity will help elucidate the best treatment option as the examiner determines whether the toe is still flexible or not. It is advisable to assess palpable pulses, since their presence is associated with a good prognosis for healing after surgery.

Tests: X-rays will demonstrate the contractures of the involved joints, as well as possible arthritic changes and bone enlargements (exostoses, spurs). X-rays of the involved foot are usually performed in a weight-bearing position.

Source: Medical Disability Advisor



Treatment

Hammertoes that are not painful (asymptomatic) and still flexible may not require treatment. In mild cases, open-toed, low-heeled, or wider shoes and foam or moleskin pads can provide symptomatic relief by reducing pressure. Taping (strapping) the affected toe can help to reduce deformity and pain. Physical therapy to instruct patients in exercises that passively stretch tight structures and strengthen weak foot intrinsic muscles is also helpful with mild cases. Periodic trimming (debridement) of corns (clavi, helomata) by a podiatrist can provide temporary relief. Corticosteroid injections are often very effective in reducing pain.

Surgical correction is necessary in more severe cases and may consist of removing a bone spur (exostectomy); removing the enlarged bone and straightening the toe (arthroplasty), sometimes with internal fixation using a pin to realign the toe; shortening a long metatarsal bone (osteotomy); fusing the toe joint and then straightening the toe (arthrodesis); or simple tendon lengthening and capsule release in milder, flexible hammertoes (tenotomy and capsulotomy). The procedure chosen depends in part on how flexible the hammertoe is.

Mild deformity (toe still flexible, no fixed flexion contracture) may respond to cutting and lengthening and/or repositioning a tendon (tenotomy) on the bottom of the foot (flexor digitorum longus). In cases of moderate deformity in which the joint contracture is partially fixed, the toe position is corrected via arthroplasty or arthrodesis. With a severe deformity (stiff, inflexible joint), the toe joint may need to be stabilized with pins or Kirschner wires (K wires) in addition to arthroplasty and tenotomy (“Hammer Toes”).

The goal of all procedures is relief of pain, not improvement in appearance.

Source: Medical Disability Advisor



Prognosis

In mild cases, conservative treatment relieves symptoms. Individuals treated surgically usually heal well, with complete symptomatic relief. Joint fusion procedures relieve pain but leave the toes stiff.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Orthopedic (Orthopaedic) Surgeon
  • Sports Medicine Physician

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Long-standing hammertoe deformity can result in arthritic changes in the joint, causing the joint to become stiff or fixed (ankylosis) or arthritic bone enlargements (spurs or exostoses) to develop.

Source: Medical Disability Advisor



Factors Influencing Duration

The method of treatment may influence the length of disability, with individuals undergoing surgery requiring the longest disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work requiring walking or prolonged standing may have to be restricted or modified if surgery is performed. This restriction will continue until the surgical areas are healed. Following surgery that uses pin fixation (internal fixation) of the bones, individuals may be able to bear weight using a stiff-soled shoe if the pin does not cross the MTP joint; otherwise, individuals may not bear weight on the affected foot for 4 to 6 weeks until the pin has been removed by the surgeon (Watson). Individuals undergoing toe fixation with K wires may be unable to bear weight for 3 weeks after surgery (“Hammer Toes”). The individual may need to wear a stiff-soled or surgical shoe and be restricted from driving, and may require frequent rest breaks to elevate the foot to control swelling. If the individual requires postoperative pain medications, drug policies need to be reviewed.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • What type of toe deformity does individual have? Is it painful?
  • Did x-rays confirm the diagnosis?
  • Has individual tried open-toed or wider shoes? Shoes with low heels? Did that provide relief?
  • Is toe deformity flexible? Fixed? Can examiner straighten toe?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • Did individual try foam or moleskin pads? Did that provide relief?
  • Did individual have corns trimmed by a podiatrist? Did that provide relief?
  • Did individual receive corticosteroid injections? Did that reduce the pain?
  • Did individual participate in physical therapy? Did that provide relief?
  • Did individual require surgery? Were pins or K wires used?

Regarding prognosis:

  • Does individual have any comorbid conditions, such as diabetes or peripheral vascular disease, that might influence disability?
  • Has individual developed arthritic changes in the toe?

Source: Medical Disability Advisor



References

Cited

"Hammer Toes." Wheeless' Textbook of Orthopaedics. 23 Jan. 2009. Duke Orthopaedics. 23 Jun. 2009 <http://www.wheelessonline.com/ortho/hammer_toes>.

Schrier, J. C. M., C. C. Verheyen, and J. W. Louwerens. "Definitions of Hammer Toe and Claw Toe: An Evaluation of the Literature." Journal of the American Podiatric Medical Association 99 3 (2009): 194-197.

Watson, Anthony. "Hammertoe Deformity." eMedicine. Ed. Heidi M. Stephens. 10 Mar. 2009. Medscape. 23 Jun. 2009 <http://emedicine.medscape.com/article/1235341-overview>.

Source: Medical Disability Advisor