Claw Toes

What is it?

As many people age, they develop claw toes. Claw toes can make fitting into restrictive shoes uncomfortable. This condition can create symptoms in one or all of three places (See Figure #1):

1. on the top of the toes if they rub against the shoes
2. on the tips of the toes if they jam in to the soles of the shoes
3. in the metatarsophalagenal (MTP) joints if as they become subluxed (displaced partially out of joint)

In addition, claw toes are often associated with 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.

Clawtoe deformities typically involve all four lesser toes. It is not uncommon for the second toe to have the most pronounce deformity, but a close look at all four toes will often demonstrate that the deformity is present in each toe (See Figure 2). 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 MTP joint (in hammertoes this joint is not displaced). However, it is very difficult to clinically differentiate between the two, so they are often used interchangeably.

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 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.

Cause of Claw Toes

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. Commonly, 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 flexion 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.

Treatment

Non-Operative Treatment

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

1. 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.
2. The use of the wide-toe box. A slight change in the shoe wear to create more room, can accommodate the deformity and make a huge difference in the patient’s symptoms.
3. 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.
4. Trimming painful calluses. If prominent calluses have developed, trimming these back on a regular basis can be very helpful.
5. Dynamic intrinsic muscle exercises. This has been proposed as a way to lessen the progression of claw toe 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. It is important to appreciate that 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:

1. Proximal Interphalangeal joint (PIP) joint resection. If there is a fixed deformity at the PIP joint, this joint can be resected, or repositioned in a straightened position and then fused with some type of fixation, often a K-wire. This joint may not fully heal, but even a fibrous union in a straight position will be effective.
2. MTP joint capsulorraphy. Because the MTP joint flexes up, the top part of the joint capsule 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 fixed with a wire in the new "straighter" position.
3. Extensor tendon lengthening. Often the 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. The toes will usually need to be fixed in this position for a period of 4 6 weeks in order to allow the tendons to heal in the new, lengthened position.
4. Flexor to extensor tendon transfer [Girdlestone Taylor procedure]. This procedure involves a release of the flexor digitorum longus at the tip of the toe (distally) and a transfer of this to the top (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.

Recovery from Surgery

It is important to realize that the recovery from any toe surgery can be more prolonged than a patient may initially think. During the healing process, an increase in blood flow to the involved toe occurs, which creates swelling and pain. This could persist for many weeks or even months. It is common to still have swelling 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.

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 Clawtoe corrections include:

• Malunion: When the PIP joint is resected and fused a malunuin can occur if this joint is not positioned correctly or if the position of the joint changes following surgery. This can result in a crooked toe. The toe may be malpositioned even to the point where further surgery is required.
• Recurrence of the Deformity: Other complications include failure to fully correct the clawtoe 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.