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Claw Toes

Definition

The most common toe deformities are hammer toes, claw toes, and bone spurs. These involve the lesser toes (2nd through 5th toes). In a hammer toe, the toe is bent at the middle knuckle of the toe, while in a claw toe the toe is bent at both the middle knuckle and tip of the toe. A bone spur can occur anywhere on the toes but most commonly affects the 4th and 5th toes. Each of the deformities can create corns on the toes and in more severe cases redness, swelling, and even an open sore can develop. It is important to note that the corns are not a skin problem! They develop because the skin is being crushed and irritated between the bones in your toes and your shoe.

You are usually born with the foot type that predisposes you to hammer and claw toes. People with flat feet, high-arched feet, or really flexible feet are more prone to develop these problems. Other causes are excessively long toes, tendon imbalance, injury, rheumatoid arthritis, and neuromuscular disease. Over time, the mechanics of your foot and shoe gear increases the deformities. Women are more frequently affected, probably because of the type of shoe they wear and the use of tight stockings.

A claw toe is a toe that is contracted at the PIP and DIP joints (middle and end joints in the toe), and can lead to severe pressure and pain. Ligaments and tendons that have tightened cause the toe’s joints to curl downwards. Claw toes may occur in any toe, except the big toe. There is often discomfort at the top part of the toe that is rubbing against the shoe and at the end of the toe that is pressed against the bottom of the shoe. Claw toes are classified based on the mobility of the toe joints. There are two types – flexible and rigid. In a flexible claw toe, the joint has the ability to move. This type of claw toe can be straightened manually. A rigid claw toe does not have that same ability to move. Movement is very limited and can be extremely painful. This sometimes causes foot movement to become restricted leading to extra stress at the ball-of-the-foot, and possibly causing pain and the development of corns and calluses.

Summary

Claw toes can develop in many people as they age, and can make fitting into restrictive shoes uncomfortable. This condition can create symptoms in one or all of three places:

On the top of the toes if they rub against the shoes

On the tips of the toes if they jam in to the soles of the shoes

At the base of the toes (metatarsophalagenal (MTP) joints) as they become subluxed (displaced partially out of joint)

In addition, claw toes are often associated with forefoot pain (metatarsalgia) as the MTP joints commonly become subluxed in patients with pronounced claw toes. This leaves the metatarsal heads prominent and subject to excessive overload.

Cause

Claw toes result from a muscle imbalance which causes the ligaments and tendons to become unnaturally tight. This results in the joints curling downwards. Arthritis can also lead to many different forefoot deformities, including claw toes.

Clinical Presentation

Claw toes result from an inherent muscle imbalance. It is common for patients to develop claw toes as they get older. It is particularly common if there is a family history of the condition. Patients develop claw toes when the long muscles originating from the lower leg overpower the smaller muscles in the foot. This imbalance leads to flexion at the proximal interphalangeal joint and extension at the metatarsal phalangeal joint, creating the clawing effect. This condition can also occur in post-traumatic situations, when there is an injury to one of the tendons or if there is a compartment syndrome affecting the small muscles of the foot.

Physical Examination

On physical examination, the physician will want to identify the main areas of tenderness. This will give some indication as to the cause of the pain. If the tenderness is on the top of the toes and is associated with some callus formation, symptoms are likely from direct pressure on the top (dorsal aspect) of the toe. If tenderness occurs on the tip of the toe, this may be from dynamic driving of the tip of the toe (“hammering”) into the sole of the shoe. In addition, whether or not the toes are flexible or fixed is important. Each joint will be reviewed to assess whether this joint can return to its normal position. The overall alignment of the toes are important, as well as the sensation and motor function of the toes.

The severity of the deformity may not correlate with the degree of pain. For example, a hammer toe or claw toe that looks severe may have no pain; while mild looking deformities may be incapacitating.

Pain and corns usually develop over the toes due to the friction of the shoe in that area. This rubbing of the shoe may cause a red, inflamed sac of tissue called bursitis. Initially, the deformities are flexible and can bet treated with simple measures but, if left untreated, they can become rigid or stiff and cannot be straightened. As time goes on, pain may develop deep in the toe joints and even the ball of the foot, limiting walking, exercise or even just standing comfortably. High heeled or pointed shoes and tight stockings will exacerbate these symptoms.

Hammer toes and claw toes are sometimes caused or made worse by a bunion deformity involving the big toes. When the big toes start to angle over, the big toe may cause increased pressure on the second toe or the second toe may be pushed upwards out of the way. This is one cause of hammer toes and claw toes.

Treatment and Prevention

Changing the type of footwear worn is a very important step in the treatment of claw toes. When choosing a shoe, make sure the toe box (toe area) is high and broad, and can accommodate the claw toes. A shoe with a high, broad toe box will provide enough room in the forefoot area so that there is less friction against the toes. Other conservative treatments include using forefoot products designed to relieve claw toes, such as toe crests and hammer toe splints. These devices will help hold down the claw toe and provide relief to the forefoot. Gel toe shields and gel toe caps are also recommended to eliminate friction between the shoe and the toe, while providing comfort and lubrication.

Non-Operative Treatment

Most claw toe deformities can be treated non-operatively. The literature describes a number of potential treatments including:

Applying pads to the area involved. There are numerous commercially available devices, which can be highly effective in reducing the deformity and providing padding to the areas of prominence.

The use of the wide-toe box. A shoe with more room up front might be better able to accommodate the deformity and make a huge difference in the patient’s symptoms.

A soft pre-fabricated orthotic to create cushioning over the toe region can be helpful, particularly if the symptoms occur at the tip of the toes.

Trimming painful calluses. If prominent calluses have developed, trimming these back on a regular basis can be very helpful.

Dynamic intrinsic muscle exercises. This has been proposed as a way to lessen the progression of clawtoe deformity. Exercises such as trying to pick up tissues with the toes may be beneficial to keep the toes supple.

 Operative Treatment

Surgery is occasionally recommended to correct claw toes that cannot be successfully treated non-operatively. There are a variety of procedures that have been described, and often a combination of procedures is performed. Because the deformity occurs as a result of a muscle imbalance, tendon transfer or lengthening may be needed in order to enact a long-term correction and minimize the risk of a recurrence. Common procedures that may be used in combination with others include:

Straightening the Toe (Proximal Interphalangeal (PIP) joint resection). If there is a fixed deformity at the PIP joint (the first “knuckle” of the toe), this joint can be removed, or repositioned in a straightened position and then fused with some type of fixation, often a wire insert through the toe. This joint may not fully heal with bone, but even a fibrous union (scar tissue) in a straight position will be effective.

MTP joint (joint at he base of the toe) soft tissue release (capsulorraphy/capsulotomy). Because the MTP joint flexes up, the top part of the joint capsule (soft tissue) becomes very stiff and contracted. It is often necessary to release this, in order for the joint to fall back into the normal position. The MTP joint is held with a temporary wire in the new “straighter” position.

Extensor tendon lengthening. Often the tendons that pull the toe upwards (long extensor tendons originating from the extensor digitorum longus muscle) will become contracted and tight. These tendons can be lengthened to allow the toes to fall back into an improved position.

Flexor to extensor tendon transfer. This procedure involves a release of one of the tendons that pulls the toe downwards (the flexor digitorum longus) at the tip of the toe (distally) and a transfer of this tendon to the top of the toe (dorsal aspect of the proximal phalanx). This procedure aims to convert one of the primary deforming forces leading to clawing of the toes into a force that helps correct the deformity. It produces a fairly predictable correction of the toes, however, the surgery is slightly more involved than some of the other procedures.

When hammer toes and claw toes are causing mild to moderate pain, the simplest solution to try is a wider, more accommodating shoe to allow room for the toes to move. This includes lower heels, softer leather, wider toe boxes, and gym shoes. Use of a pumice stone to thin any corns and callouses is sometimes helpful. Cushions and various soft pads may provide relief from shoe pressure over the toes. Never use a “medicated” corn pad since these contain a strong acid which does not know the difference between the bad and good skin and can lead to a chemical burn or deep open sore which can become infected.

When the hammer toes and claw toes are painful despite the conservative therapy options, or you cannot find shoes that are comfortable, surgical correction should be discussed with your podiatric physician. The longer surgery is delayed in a symptomatic foot, the greater the amount of deformity that develops, and the more complicated the surgery becomes. Patients who have their symptomatic hammer toes and claw toes corrected earlier tend to have greater satisfaction after the procedure. When these treatment options are no longer providing the comfort you need, consultation with your podiatric physician is advised to discuss surgical options.

Potential Complications

General Complications

The usual list of general post-surgical complications may occur with a clawtoe correction. This includes the potential for

wound healing problems

infection

nonunion (if the PIP joint is fused)

local nerve injury to the nerves that provide sensation to the tips of the toes

Deep Vein Thrombosis (DVT) – very uncommon

Pulmonary Embolism (PE) – very uncommon

Specific Complications

Complications that are specific to claw toe corrections include:

Malunion: It is common for the toe to heal in a position that may not be   perfectly straight. Minor degrees of deformity will be mostly a cosmetic concern, which is why almost all surgeons discourage patients from having toe surgery if the concerns are mostly cosmetic. In severe cases, the toe may be significantly malpositioned even to the point where further surgery is required.

Recurrence of the Deformity: Other complications include failure to fully   correct the claw toe deformity or the potential for recurrence of the deformity over time.

Loss of blood supply to the tip of the toe. The blood supply to the tip of the toe can be tenuous. There are two small arteries (one on either side of the toe) which supply blood to the tip of the toe. It is not uncommon for one of these vessels to be absent. If the blood supply to the tip of the toe is lost the tissue will die and it may be necessary to amputate part, or all of the toe.

Recovery from Surgery

It is important to understand that the recovery from any toe surgery is often more prolonged than a patient expects. During the healing process, an increase in blood flow to the involved toe occurs. This creates swelling and pain. This could persist for many weeks or even months. It is common to still have swelling and stiffness in the toes 4-6 months post-surgery. The patient should be prepared to limit their activity for a period that is often longer than they think, or would like.

 What Does Surgery Involve?

The goal of surgical correction is to restore normal alignment and function of the toe joint. If the toes are still flexible the tight tendons can be released and the toe straightened through a small poke-hole in the skin. If the toe is rigid, the knuckle is straightened and returned to a normal alignment. A small pin is sometimes placed inside the bones to hold the toe in proper position while it heals. The pin does not stick out the end of the toe and very rarely needs to be removed. If the joint is destroyed from arthritis beyond repair, it may need to be replaced with an artificial joint. If a bone spur is the cause of the problem this is filed down through a small poke-hole in the skin.

Following surgery, the foot is bandaged and a post operative shoe is worn for one week. Athletic shoes may be worn after the first week. Exercise and prolonged standing are restricted for the first 6-8 weeks. A home exercise program is important for regaining the strength and flexibility. You may steadily resume activities and wear more fashionable shoe gear as healing occurs, and in consultation with your surgeon.