Claw toe is a type of lesser toe deformity.

Before describing the deformity, you may wish to read about the normal anatomy of the lesser toes here.

In a claw toe the normal anatomy is distorted.

There is flexion at the DIP and PIP joints, with hyperextension of the MTP joint.

Claw toe deformity

Typically all of the toes including the big toe are involved and often it affects both feet (bilateral)

In the early stages of the condition the toe may still remain flexible and the deformity correctable on passive manipulation of the toe. As the condition progresses the deformity becomes fixed.

A claw toe occurs due an imbalance in the muscles that control toe movement. The powerful extrinsic muscles (in the leg) that straighten (extensor) and bend (flexor) the toe are not balanced by the intrinsic muscles (in the foot) which are too weak or under active.

The primary problem is hyperextension at the MTP joint due to the overactivity of the extrinsic extensor muscles (originate in the leg and not foot) EDL and EHL.  In addition the intrinsic foot muscles are either not strong enough or too weak and the extrinsic flexors (FDL and FDB) which bend the toe at the DIP and PIP joints.

An illustration of a claw toe with tendons

In a normal foot on their way to their respective attachments on the toe, the EDL and EDB tendons blend with a structure called the extensor hood at the level of the MTP joint and proximal phalanx. The extensor hood is an important structure in the toe. It is a complex, triangular sheath, with a hood-like appearance, that functions as the tendinous attachment of the extensor digitorum longus but also the intrinsics: lumbrical, plantar interossei, and dorsal interossei muscles. The extensor hood blends into the plantar plate and MTP joint capsule on the undersurface of the toe. Contraction of the intrinsics with the toe in neutral act as flexors of the toe at the MTP joint because the attachment is below the axis of the MTP joint. Due to the attachment of the intrinsics to the extensor hood as they contract, they tighten the extensor hood which in turns straightens the toe at the DIP and PIP joints.

The extensor hood (yellow) implicated in claw toe

When the intrinsic muscles contract, the long extensor contraction (EDL) is distributed through the extensor hood equally to all the joints, and as a result the toe is extended (straightened) with DIP & PIP joints straight.

Intrinsic contraction tightens the extensor hood which in turn straightens the DIP and PIP joints

Without intrinsic function, contraction of the long extensors (EDL) produces hyperextension of the MTP joint through the extensor sling, but no extension of the DIP & PIP joints which are then flexed by the long flexors (FDL & FDB).

Result of extrinsic function unopposed by intrinsic activity

Eventually the plantar plate ligament becomes weakened, the toe starts to drift dorsally and the little activity of the intrinsic muscles makes the problem worse. With the toe hyperextended the intrinsic force is now dorsal to the axis of the MTP joint.

Illustration of claw deformity and resulting abnormal forces

Tight calf muscles (gastrocnemius) are not known to cause claw toe deformity, however we mention it as it can exacerbate the problem. Tight calf muscles result in an increase load across the front of the foot, this puts more strain on already damaged structures such as the plantar plate ligament. Addressing calf tightness is important in the treatment of claw toe.

The following conditions are associated with claw toe and may have a role in its development:

• Synovitis (inflammation of the MTP joint)
• Inflammatory conditions such as rheumatoid arthritis
• Trauma
• Constricting footwear causing crowding of toes and high heeled footwear leads to forced hyperextension at the MTP joint
• Post compartment syndrome of the foot or leg
• High arched (Pes Cavus) foot
• Diabetes
• Increasing age
• Neurological conditions that cause an imbalance in the foot muscles (extrinsic and intrinsic)
  • Charcot Marie Tooth
  • Stroke
  • Polio

Pain is the main symptom. It can arise due to a number of reasons:

• Loss of lesser toe load sharing (in late stance phase of the gait cycle)
• Plantar fat pad distal migration
• MTP joint synovitis
• Downward pressure by toe on metatarsal head (plunger effect described by Stainsby)
• On the top of the toes as they rub against the shoes (typically the PIP joint)
• On the tips of the toes due to increased pressure over a small area
• At the MTP joints as they become subluxed or dislocated
• Metatarsalgia

As the toe hyperextends at the MTP joint, it displaces a pad of fat which normally sits under the MTP joint (ball of the foot). The MTP joint therefore loses its natural protective cushion.

The position of the plantar fat pad in a toe with neutral alignment

Distal migration of the plantar fat pad on hyperextension of the toe

MRI of the foot demonstrating distal migration of the fat pad in a patient with a claw toe deformity

As mentioned above the loss of normal anatomy results in increased forces going across the MTP joint as well as loss of the normal protective mechanisms. This can cause significant pain and disability.

Illustration of claw deformity and resulting abnormal forces

The body responds by thickening the skin under the ball of the foot. This is called a callosity. Many patients have the callosity removed but it eventually comes back. This is because as long as there exists abnormal foot biomechanics and pressure, the body will naturally compensate with its protective mechanism which is to create a thicker pad of skin.

Focal callosity under the 2nd MTP joint

Patients can also get painful callosities at the tips of toes due to increased focal pressure and where they rub against footwear.

Clinical picture of focal callosity under the 2nd MTP joint and at the tip of the 3rd toe

Metatarsalgia (pain in the metatarsals) is a common complaint and results due to the loss of the plantar fad pad and excessive loading across the MTP joints.

Clinical picture demonstrating the abnormal position of the plantar fat pad in a patient with clawed toes

Radiographs will be arranged at your initial clinic consultation. These will help confirm the diagnosis, the severity of the deformity and aid in pre operative planning.

If there is an underlying neurological condition further tests may be requested.

Claw toe is a condition that can get worse over time.

The deformity can be flexible and passively correctible in the early stages but with time it can become fixed. The deformity can also increase and the toes finally dislocate at the MTP joints.

Complications include painful callosities and ulcers (a break in the skin) which can become infected.

Infected ulcer on the dorsum of the toe

This patient had an ulcer form at the site of their callosity which subsequently became infected

Non-operative management aims at relieving pain and limiting deformity progression. It is likely to be most effective in the early stages of the condition.

It should always be the first line treatment. Options include:

Toe sleeves

Made of silicon can be worn over the toe to protect from direct pressure and rubbing against footwear.

Taping/strapping

Helps position the toe in neutral alignment using cross over taping or toe straps. It also provides stability to the joint and helps alleviate symptoms. The key is to hold the proximal phalanx parallel to the ground. if the deformity is of recent onset, one can use pads over the corns.

Insoles & orthotics

A custom insole with plenty of padding can take some of the pressure off the joint and alleviate pain. A metatarsal bar insole may also provide symptomatic relief.

Splints are commercially available that can help maintain the toes in a corrected position. thee key is to hold the proximal phalanx parallel to the ground.

Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from an inflamed synovitic MTP joint.

Footwear

The use of stiff soled shoes that do not bend and therefore protect the MTP joint. Wearing a shoe with a wide and deep toe box to minimise painful rubbing.

Physiotherapy

Stretching tight calf muscles will help reduce the forces going across the forefoot. This will help reduce pain in the MTP joint.

Dynamic intrinsic foot muscle exercises. These exercises may limit the progression of claw toe deformity.

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. Often a combination of procedures is performed. Because the deformity results from a muscle imbalance, tendon transfer or lengthening may be needed in order to achieve a correction and minimise the risk of recurrence. When planning surgery it is important to note whether the deformity is fixed or flexible.

The most common procedures that may be used in combination with others include:

For flexible claw toe deformity

• Extensor tendon lengthening (EDB & EDL) – Releasing these tight tendons allows the toe to return to a more normal position.
• MTP joint capsular release – Over time the joint capsule tightens up, releasing the capsule allows the toe to return to a more normal position.
• FDL flexor to extensor tendon transfer (Girdlestone-Taylor procedure) – This procedure involves releasing one of the tendons that pulls the toe downwards (FDL) at the end of the toe. the tendon is then transferred to the top of the toe (dorsal aspect of the proximal phalanx and extensor hood). This procedure aims to convert one of the primary deforming forces that results in clawing of the toes into a corrective force. It is a technically more demanding operation and recovery is slightly longer as a result.

For fixed claw toe deformity

• Extensor tendon lengthening (EDB & EDL)
• MTP joint capsular release
• FDL flexor to extensor tendon transfer (Girdlestone-Taylor procedure)
• PIP joint fusion/arthroplasty – Bringing the toe down is not enough in a fixed deformity, the fixed bend at the PIP joint has to be corrected and this is done by removing some of the joint and fusing the toe in a corrected straightened position. It is not unusual for this joint not to fully heal with bone, but even a fibrous union (scar tissue) in a straight position will be effective in the majority of patients. The bones are held in place by a temporary metal wire (K wire) which is removed at roughly 4-6 weeks.
• Shortening Weil’s metatarsal osteotomies (all lesser toes) – By shortening the metatarsal bone the aim is to correct the imbalance in the soft tissues indirectly.

Chronic Dislocation

• May require transfixing the toe to the metatarsal with a K wire.
• In the presence of severe infection or uncorrectable deformity resulting in significant symptoms, rarely an amputation may be considered.

Minimally Invasive Surgery (MIS)

• Some of the above procedures will be attempted in the first instance using a minimally invasive surgical technique.

The aim of surgery is to correct the deformity, alleviate pain and return a patient to full function.

X-rays showing before (left) and after (right) claw toe corrective surgery

It should be borne in mind that complications can result from a condition with or without surgery.

Potential complications of non-operative treatment include:

• Worsening pain
• Increasing deformity
• Dislocation of the lesser toes
• Formation of ulcers on the sole of the foot (plantar aspect of MTP joint)
• Formation of ulcers across the top (dorsum) of the second toe as it rubs against the shoe
• Infection of ulcers

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

• Risks and complications of anaesthesia
• Bleeding
• Infection (superficial and deep)
• Blood clots
• In the case of an MIS procedure it may be necessary to proceed to open surgery if during the operation it is felt that a better outcome will be achieved using an open technique
• Failure to fully correct deformity (particularly if longstanding deformity)
• Need for further surgery
• Complex regional pain syndrome

Potential specific complications of operative treatment of claw toes include:

• Painful non union of the PIP joint
• Recurrence of the deformity
  • Failure to fully correct the claw deformity
  • Recurrence of the deformity over time – most likely due to plantar plate dysfunction
• Malunion
  • It is not uncommon for the toe to heal in a position that may not be perfectly straight
  • Minor deformity will be mostly a cosmetic issue, which is why almost all orthopaedic foot and ankle surgeons discourage patients from having toe surgery if the underlying issue is cosmetic
  • In the unlikely event of  severe malunion, further surgery may be required
• Floating toe
  • Complication of Weil’s osteotomy
  • Occurs as a result of the intrinsic attachment migrating dorsal to the MTP joint axis and therefore acting as a toe extensor
• Stiffness of the MTP joint
• Wound healing problems (particularly when correcting a chronic deformity the soft tissue can become contracted)
• In chronic deformity the blood vessels contract, straightening the toe stretches these vessels potentially compromising the blood supply
  • 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
  • This is a very small risk
• Nerve injury to the toes causing numbness

Note – these complications are not exhaustive and are meant as a guide

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.

Immediate post operative period

Almost all surgical procedures for claw toe deformity will be undertaken as a day case.

You will have a bandage applied similar to this during the operation.

Post operative bandage of the foot

Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.

Post operative stiff soled shoe

For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.

High foot and ankle elevation following surgery

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.

Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped.

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.

Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 weeks before any driving is advisable.

Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.

Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.

Six weeks post operatively

You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 weeks to heal.

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.

You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.

Three months post operatively

Final clinical examination. Discharge if satisfactory.

When can I wear normal shoes?

This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a stiff soled shoe with a wide toe box while your foot continues to heal.

When can I drive?

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.

When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.

What should the final outcome be?

Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.