The difficulty of straightening toes is a frequent mobility challenge following a stroke. This condition, sometimes referred to as flexor synergy, significantly impairs a person’s ability to walk safely and maintain balance. Addressing this involuntary toe curling is an important focus of rehabilitation, as it is a necessary step toward improving overall gait and regaining independent mobility.
Why Toes Curl After a Stroke
The neurological damage caused by a stroke disrupts the brain’s control over the muscles, leading to an imbalance in the signals sent to the foot. The primary mechanism behind toe curling is a combination of muscle spasticity and muscle weakness. Spasticity causes the flexor muscles, which bend the toes downward, to become overactive and constantly contracted. This overactivity causes an involuntary, excessive tightening of the muscles and tendons on the bottom of the foot.
This overactivity is not properly counteracted because the opposing extensor muscles, which should lift and straighten the toes, are often weakened or paralyzed. The powerful flexor muscles overpower the weak extensors, causing the joints of the toes to buckle into a curled position. This muscle imbalance can also be linked to spasticity in the calf muscles, which indirectly contribute to the toe flexion. The condition can be classified as “flexible,” where the toes can still be manually straightened, or “rigid,” where the deformity has become fixed and more difficult to correct.
Active and Passive Home Exercises
Consistent, daily exercises are the most immediate and accessible strategy for managing toe curling and retraining the brain-muscle connection. Passive Range of Motion (PROM) exercises are foundational, focusing on gently stretching the contracted muscles to maintain flexibility and prevent the tendons from shortening. A caregiver or the person themselves can manually straighten the curled toes and gently flex the foot upward toward the shin, holding the stretch for 30 seconds to lengthen the calf and foot muscles.
Active exercises focus on re-engaging the brain’s signals to the weakened muscles responsible for lifting the toes. A simple and effective movement is “toe tapping,” where the person attempts to lift only the toes while keeping the heel and ball of the foot flat on the floor. Another exercise involves lifting the big toe up while simultaneously pressing the other four toes down, and then reversing the movement. These movements must be repeated multiple times to promote neuroplasticity and improve control over the affected muscles.
Intrinsic foot muscle strengthening can be achieved by placing a small towel on the floor and using the toes to scrunch and pull the towel toward the body. These gripping exercises help to build control and coordination within the small muscles of the foot. It is important that all exercises, especially stretching, are performed consistently and that any discomfort is monitored, stopping immediately if any pain develops.
Supportive Devices and Bracing Options
External devices provide passive support to maintain proper toe and foot alignment, which is particularly helpful during periods of rest or walking. Ankle-Foot Orthoses (AFOs) are braces that extend from below the knee to the foot, stabilizing the ankle and preventing foot drop. By controlling the ankle’s position, AFOs indirectly reduce the tension contributing to toe curling and provide a more stable base for walking.
Specialized toe spacers or separators fit between the toes to keep the digits separated and straight. Wearing these devices helps reduce abnormal muscle tone and prevents the toes from rubbing against each other or the shoe. For maintaining a therapeutic stretch over a long duration, night splints are recommended to hold the foot in a dorsiflexed (upward) position while sleeping. This prolonged stretch helps to counter the muscle shortening that occurs from spasticity. These supportive aids are typically introduced under the guidance of a physical therapist.
Specialized Therapeutic Interventions
When home exercises and bracing are not fully effective, professional medical interventions offer next-level treatment options. Physical and occupational therapists (PT/OT) provide comprehensive care, including gait training to correct walking patterns and advanced stretching techniques. Therapists may also utilize Neuromuscular Electrical Stimulation (NMES), which involves applying small electrical currents to the skin over weakened muscles to elicit a contraction. This stimulation helps the brain reconnect with the foot muscles, contributing to reduced spasticity and increased range of motion.
A highly effective treatment for focal spasticity, including severe toe curling, is the targeted injection of Botulinum Toxin (Botox). This neurotoxin is injected directly into the overactive flexor muscles to temporarily block the release of neurotransmitters that cause muscle contraction. The result is a temporary relaxation of the muscle, which reduces the involuntary curling and allows for easier stretching and functional movement. The effects of a Botulinum Toxin injection typically last for three to six months, and the treatment is most beneficial when combined with intensive physical therapy.