Claw toe is a common foot deformity where the joints of the smaller toes (second through fifth) bend into an unnatural, claw-like position, causing them to curl downward and creating discomfort. It is a progressive condition that often begins as a flexible misalignment but may eventually become rigidly fixed over time. Early identification and intervention are necessary, as claw toe can severely impact mobility and the ability to wear standard footwear.
Anatomy of the Deformity
Claw toe is defined by a distinct, three-joint misalignment in the lesser toes. The metatarsophalangeal (MTP) joint, closest to the foot, is pulled into hyperextension (bending upward). This upward bend initiates the deformity. The proximal interphalangeal (PIP) joint and the distal interphalangeal (DIP) joint both flex or curl downward toward the sole of the foot. This combination of upward bending at the base and downward curling gives the condition its characteristic claw shape. This full-toe involvement differentiates claw toe from hammertoe (PIP joint only) or mallet toe (DIP joint only). Over time, the soft tissues shorten, leading to a permanent, fixed contracture.
Primary Causes and Contributing Factors
The formation of a claw toe is predominantly due to an imbalance between the intrinsic and extrinsic muscles of the foot. Intrinsic muscles are small muscles located within the foot that stabilize the toes. When these muscles become weak or paralyzed, they are overpowered by the stronger extrinsic muscles, which run from the lower leg into the foot.
Neurological conditions frequently cause this muscle imbalance by leading to atrophy and weakness in the intrinsic foot muscles. Examples include nerve damage from diabetic neuropathy and Charcot-Marie-Tooth disease. When intrinsic muscles fail, the long flexor and extensor tendons from the lower leg exert an unopposed pull, resulting in the characteristic hyperextension at the MTP joint and flexion at the PIP and DIP joints.
Inflammatory joint diseases, such as rheumatoid arthritis, are another factor. Chronic synovitis (inflammation of the joint lining) can destroy cartilage and weaken ligaments, causing joint instability that allows the toe to drift into the clawed position. Extrinsic factors like ill-fitting footwear also contribute, particularly shoes with a narrow toe box or high heels that force the toes into a cramped, hyperextended position.
Recognizing Secondary Symptoms
The structural change in a claw toe creates abnormal pressure and friction, leading to several painful secondary symptoms. The upward-buckled PIP joint frequently rubs against footwear, causing hard corns to develop on the top of the toe. Conversely, the curled toe tip and the ball of the foot bear excessive weight, resulting in the formation of thickened calluses. These dense areas often form underneath the metatarsal heads, causing deep forefoot pain known as metatarsalgia.
The change in foot structure also compromises stability and gait. The clawed position reduces the toe’s ability to properly grip the ground and assist in the push-off phase of walking. This leads to an altered walking pattern and difficulty maintaining balance, increasing the risk of falls.
Treatment and Management Options
Initial management of claw toe focuses on non-surgical methods, especially while the deformity remains flexible. The first step involves modifying footwear to shoes with a deep, wide toe box that can accommodate the curled toes without rubbing. Non-prescription devices like toe crest pads or splints can be used to manually hold the toes in a straighter, more neutral position, offering immediate relief from friction.
Custom-made orthotic inserts can provide arch support and help redistribute pressure across the entire foot, reducing the load on the metatarsal heads and alleviating callus formation. Specific stretching and strengthening exercises, such as toe extension stretches or attempting to pick up small objects with the toes, are recommended to maintain flexibility and strengthen the remaining intrinsic muscles. These conservative measures are most effective when the toe is still flexible.
If the toe becomes rigid, painful, and unresponsive to conservative care, surgical correction may be necessary to restore normal function. For flexible deformities, a surgeon might perform a soft-tissue procedure like a flexor tendon transfer, rerouting a tendon to help pull the toe flat. For rigid deformities, a bony procedure is required, such as a joint fusion (arthrodesis) or joint resection (arthroplasty) of the PIP joint, where bone is removed to physically straighten the toe.