The experience of having toes curl downward after a stroke, often called claw toe or toe flexion deformity, impacts the ability to walk, challenges balance, and can lead to discomfort and skin breakdown due to friction in shoes. Addressing this issue is central to regaining mobility and comfort after a stroke. This article outlines the reasons behind this curling and provides actionable strategies, from daily stretching to clinical options, to help straighten the toes and promote better function. This information is for educational purposes only and is not a substitute for personalized medical or physical therapy advice.
Why Toes Curl After a Stroke
The curling of the toes is a physical manifestation of a neurological problem: an imbalance in muscle tone and control caused by brain damage from the stroke. The stroke interrupts the communication pathways between the brain and the muscles, leading to a condition where the muscles on the bottom of the foot—the flexors—become overactive. This overactivity causes the toes to pull downward into a claw-like shape.
Simultaneously, the muscles responsible for lifting the toes—the extensors—become weakened, unable to counteract the constant pull of the overactive flexors. This imbalance can be compounded by an exaggerated balance response, where the intrinsic foot muscles overcompensate to maintain upright posture. The resulting imbalance tightens the tendons and ultimately causes the joints of the toes to buckle and become fixed in a curled position over time.
Daily Passive Stretching and Positioning
Managing the constant pull of the flexor muscles begins with passive stretching and proper positioning. Passive exercises involve moving the affected foot and toes without the survivor exerting effort. The goal is to maintain the length of the muscle tendons and temporarily reduce involuntary muscle tension.
A primary technique is the manual toe extension hold, where each curled toe is gently stretched upward toward the ceiling. This stretch should be held for at least 20 to 30 seconds to allow the muscle to relax, avoiding sudden movements that could trigger a reflex contraction. Gentle ankle dorsiflexion stretching is also beneficial, as the muscles that point the foot down often contribute to toe curling.
Positioning the foot and ankle correctly during rest or sleep helps prevent the toes from shortening into a fixed deformity. Specialized positioning devices or night splints can hold the ankle in a neutral or slightly upward-bent position, applying a prolonged, mild stretch to the calf and toe flexor muscles. Simple toe separators, worn during the day or night, also help minimize abnormal tone in the foot by spreading the toes.
Active Foot and Ankle Retraining Exercises
To regain voluntary control and strengthen the muscles that straighten the toes, survivors must engage in active retraining exercises. These activities specifically target the weaker extensor muscles and encourage the brain to re-establish neural connections through repetition.
- Toe tapping is performed while sitting with the feet flat on the floor. The survivor attempts to lift just the toes off the ground while keeping the heel down, focusing on isolated movement of the toes themselves.
- Towel scrunching involves curling the toes to pull a towel inward, which engages the intrinsic foot muscles. The toes should then be used to stretch the towel back out, emphasizing the extension phase.
- Marble pickup builds dexterity and control by having the survivor use the toes to grasp small objects, like marbles, and lift them into a cup.
- Ankle alphabet involves tracing the letters of the alphabet in the air with the foot, which promotes range of motion and overall foot control, indirectly impacting toe function.
Consistent practice of these movements stimulates neuroplasticity, which is the brain’s ability to reorganize and relearn how to coordinate the foot and toe muscles.
Supportive Footwear and Clinical Treatment Options
When daily stretching and active exercises require additional support, specialized footwear and clinical treatments can provide further help. Proper shoes must have a wide, deep toe box to accommodate the curled toes without creating painful pressure points or blisters. Soft, flexible materials and a firm sole provide comfort and stability during walking.
Custom orthotics or Ankle-Foot Orthoses (AFOs) are external devices often prescribed to maintain the foot in a neutral position. An AFO can prevent the foot from dropping and the ankle from turning inward, which often reduces the secondary reflex that causes the toes to curl during movement. The use of orthotics should be combined with exercises to ensure the underlying muscles are not neglected.
For persistent muscle overactivity, clinical options such as Botulinum Toxin injections (Botox) can be considered. This treatment temporarily blocks the signals that cause the spastic muscles to contract, providing a window of three to four months where the muscles are relaxed. In rare cases where the toe deformity becomes rigid and severely impairs mobility, surgical intervention to lengthen or reposition the tendons may be necessary as a final option.