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:
In addition, claw toes are often associated with forefoot pain (metatarsalgia), as the MTP joints commonly become subluxed in patients with pronounced claw toes. Subluxation is the upward displacement of the toe relative to the metarsal head or “ball of the foot.” This leaves the metatarsal heads prominent and subject to excessive overload.
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. Commonly, clawing of the toes develop if the calf muscles are tight. If the calf is tight, there is recruitment of the muscle that pulls the toes upward, the extensor digitorum longus, to assist in pulling the foot up to clear the ground while walking in preparation for the next step.
Clawtoe deformities typically involve all four lesser toes (toes 2-5). It is not uncommon for the second toe to have the most pronounced deformity, but a close look at all four toes will often demonstrate that the deformity is present in each toe (See Figure 1). It is uncommon for the big toe to develop clawing, although this does happen in certain conditions, including Charcot Marie Tooth disease.
The term hammertoe is almost synonymous with claw toes. The main difference between these two conditions is the position of the distal interphalangeal joint (DIP joint). In hammertoes this joint is extended and in a claw toe it is flexed. However, it can sometimes be difficult to clinically differentiate between the two.
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 evaluated to assess whether this joint can return to its normal position. The overall alignment of the toes is important, as well as the sensation and motor function of the toes.
Most claw toe deformities can be treated non-operatively. The literature describes a number of potential treatments including:
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:
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.
The usual list of general post-surgical complications may occur with a clawtoe correction. This includes the potential for
Complications that are specific to claw toe corrections include: