Orthopaedic Surgery - Claw Toes

Basics

Claw toes are deformities of the lesser toes characterized by hyperextension at the metatarsophalangeal (MTP) joint together with flexion of the proximal interphalangeal (PIP) joint.

The distal interphalangeal joint may be either flexed or extended, depending on the specific deformity and underlying muscle imbalance.

Epidemiology

The frequency of claw-toe deformity increases with advancing age.

It occurs more commonly in women than men.

Genetics

When claw toes result from a hereditary motor and sensory neuropathy, the underlying disorder may follow an autosomal dominant inheritance pattern.

This is particularly relevant in patients with disorders such as Charcot–Marie–Tooth disease.

Pathophysiology

The most common mechanism is an imbalance between the intrinsic and extrinsic muscles of the foot.

Weakness or loss of the intrinsic muscles allows the long flexor and extensor tendons to act without their normal balancing forces.

Development of the Deformity

The process may begin with synovitis and attenuation of the plantar plate at the MTP joint.

As the plantar plate weakens, the proximal phalanx progressively hyperextends at the MTP joint.

Role of MTP Hyperextension

Hyperextension at the MTP joint displaces the intrinsic tendons dorsally relative to the axis of the joint.

This changes their mechanical action and contributes further to flexion of the interphalangeal joints, producing the characteristic claw configuration.

Extrinsic Muscle Contracture

Concurrent tightness or contracture of the long toe flexors and extensors can worsen the deformity.

Without effective intrinsic muscle opposition, the toe becomes progressively hyperextended at the MTP joint and flexed distally.

Underlying Disorders

Claw toes frequently develop secondary to neurologic or inflammatory conditions that disrupt normal muscle balance or weaken passive ligamentous restraints.

They may also occur without an identifiable underlying disease.

Causative Factors

Associated or contributing factors include tight footwear, hallux valgus, inflammatory arthropathy, peripheral neuropathy, diabetes mellitus, hereditary sensorimotor neuropathy, neuromuscular disease, spasticity, and delayed or missed compartment syndrome.

Diagnosis

Signs and Symptoms

A prominent feature is a dorsal prominence of the PIP joint of the affected lesser toe.

This prominence may rub against footwear and produce pain, callus formation, or skin irritation.

Callosities

Repeated pressure from shoes can produce painful callosities over the dorsal PIP joint.

Plantar calluses may also form beneath the metatarsal heads because of abnormal forefoot loading.

Pain

Pain may occur over the dorsum of the toe or beneath the ball of the foot.

Pain beneath the metatarsal heads is commonly described as metatarsalgia.

Difficulty With Footwear

Patients often have difficulty finding comfortable shoes because the elevated toe rubs against the upper portion of the shoe.

This problem tends to become more severe as the deformity becomes rigid.

History

Patients may seek treatment because of pain, difficulty wearing shoes, or dissatisfaction with the appearance of the toes.

A painful bursa may develop over the dorsal PIP prominence.

Plantar Fat Pad Migration

As the MTP joint hyperextends, the plantar fat pad may shift distally away from the metatarsal head.

Loss of normal cushioning beneath the metatarsal head can contribute to painful plantar calluses.

Ulceration

In patients with loss of protective sensation, particularly those with diabetic or hereditary neuropathy, pressure points can progress to skin breakdown and ulceration.

This is an important reason for close monitoring.

Physical Examination

Claw toes often involve several adjacent digits and may be bilateral.

They are frequently associated with cavus foot deformity or Achilles tendon contracture.

Neuromuscular Examination

A complete neuromuscular examination should be performed to identify an underlying cause.

Muscle strength, reflexes, gait, and associated deformities should be assessed.

Sensory Examination

Sensation in the foot should be tested carefully.

Loss of protective sensation substantially changes treatment decisions because it increases the risk of pressure injury and ulceration.

Diabetic Neuropathy Assessment

In patients with diabetes, a Semmes–Weinstein monofilament examination can be used to assess protective sensation and identify peripheral neuropathy.

Vascular Examination

The vascular status of the foot should be assessed, particularly when surgery is being considered.

Poor circulation increases the risk of wound-healing complications and may limit operative options.

Flexible Versus Rigid Deformity

The toes should be manipulated to determine whether the deformity is flexible or fixed.

This distinction is central to treatment planning.

MTP Joint Assessment

The MTP joint should be assessed for alignment, stability, subluxation, dislocation, and pain with manipulation.

Instability at this joint may indicate advanced plantar plate insufficiency.

Imaging

Plain Radiographs

Plain radiographs may show MTP joint subluxation or dislocation and flexion deformity at the PIP joint.

Weight-bearing images can help demonstrate the severity of alignment abnormalities.

Differential Diagnosis

Hammer Toe

Hammer toe can resemble claw toe but typically involves PIP flexion without the characteristic MTP hyperextension pattern seen in a true claw toe.

Mallet Toe

Mallet toe primarily involves a flexion deformity of the distal interphalangeal joint.

The MTP joint is not characteristically hyperextended.

Treatment

General Measures

Initial treatment is usually nonoperative and directed toward relieving pressure, reducing pain, and accommodating the deformity.

Options include bracing, taping, padding, cushions, and shoe modification.

Budin Splint

A Budin splint may help maintain improved toe alignment in patients with a flexible deformity.

It is less effective once the deformity becomes rigid.

Silicone Padding

Silicone or other soft padding can protect prominent areas of the toes from friction and pressure.

This may reduce callus formation and discomfort.

Cushioned Insoles

Cushioned insoles can decrease plantar pressure and help relieve metatarsalgia.

They are particularly useful when plantar calluses are present.

Footwear Modification

Shoes with a wide forefoot and high toe box can reduce rubbing over the elevated toes.

Footwear modification is one of the most useful conservative treatments.

Geriatric Considerations

Claw toes are particularly common in older women.

When significant comorbidities such as diabetes mellitus or peripheral vascular disease are present, conservative treatment is preferred whenever possible.

Surgery should be approached cautiously because wound and infection risks may be increased.

Pediatric Considerations

Congenital curly toes may be present from birth and can resemble lesser-toe deformities.

They are usually asymptomatic and commonly managed with observation.

Surgery

General Principles

Surgical treatment depends primarily on whether the deformity is flexible or rigid.

Associated hindfoot or midfoot pathology should also be addressed because persistent proximal deformity can contribute to recurrence.

Flexible Deformity

Flexible claw toes often correct when the ankle is plantarflexed or when the toe is manually manipulated.

These deformities are primarily caused by muscle imbalance rather than fixed joint contracture.

Flexor-to-Extensor Tendon Transfer

A flexor-to-extensor tendon transfer may be used to correct a flexible claw toe.

The transferred tendon helps rebalance the toe and reduce PIP flexion and MTP hyperextension.

Rigid Deformity

Rigid claw toes require correction of contracted soft tissues and, in some cases, bone procedures.

The MTP capsule and collateral ligaments may need to be released.

Extensor Tendon Release or Lengthening

A tight extensor tendon can maintain MTP hyperextension.

Release or lengthening may therefore be necessary as part of correction.

MTP Joint Dislocation

Claw toes associated with MTP dislocation may require an oblique distal metatarsal shortening osteotomy, such as a Weil-type osteotomy.

Shortening the metatarsal reduces tension and facilitates reduction of the MTP joint.

Rigid PIP Contracture

A fixed PIP joint deformity may require partial phalangectomy or PIP joint arthrodesis.

Fusion provides stable correction when the joint can no longer be passively straightened.

Associated Hindfoot and Midfoot Deformity

Underlying cavus, hindfoot varus, Achilles contracture, or other deformities should be treated when they contribute to the forefoot abnormality.

Failure to correct these problems can increase the likelihood of recurrence.

Follow-Up

Indications for Referral

Specialist referral is appropriate when pain persists despite conservative treatment or when the deformity causes significant functional limitation.

Difficulty Wearing Shoes

Inability to wear appropriate footwear despite shoe modification is a common reason to consider operative correction.

Skin Ulceration

Ulceration or impending ulceration over a pressure point warrants prompt assessment.

This is particularly important in patients with neuropathy or diabetes.

Prognosis

Claw-toe deformity is usually progressive.

Without treatment, both the structural deformity and associated pain may gradually worsen.

Flexible deformities may eventually become fixed as capsular and tendon contractures develop.

Complications

Stiffness

Postoperative stiffness can occur, particularly after joint release or fusion procedures.

Wound Infection

Surgical treatment carries a risk of wound infection.

This risk is greater in patients with diabetes, neuropathy, or peripheral vascular disease.

Persistent Pain

Pain may continue despite technically successful correction, especially when associated metatarsalgia or neuropathy is present.

Incomplete Correction

The deformity may not be fully corrected if significant contracture or unrecognized contributing pathology remains.

Recurrence

Claw toes can recur, particularly when the underlying muscle imbalance or proximal foot deformity persists.

Floating Toe

A floating toe deformity may develop after a distal metatarsal shortening procedure such as a Weil osteotomy.

The affected toe may fail to contact the ground normally during standing or gait.

Patient Monitoring

Follow-up should assess toe alignment, flexibility, skin integrity, shoe tolerance, plantar pressure symptoms, sensation, and vascular status.

Patients with diabetes or neuropathy require especially careful surveillance for calluses, pressure injury, and ulceration.