Claw toes are a condition that affects the small toes of the foot. Similar to hammer toes, claw toes involve cocking up of the lesser toes where they join the ball of the foot as well as flexion at the small knuckles of each toe.
Unlike hammer toes, claw toes typically involve multiple digits and often involve both feet. In the majority of cases, claw toes result from an underlying medical condition or neurologic problem.
Claw toes may develop from diseases that affect the muscles and joints of the foot such as rheumatoid arthritis or lupus, which cause joint destruction and toe deformity. Neurologic conditions can also produce claw toe deformities. It is felt that the delicate balance between the small muscles in the foot and the stronger muscles in the leg becomes disrupted. The powerful leg muscles overpower the foot muscles and cause these typical deformities.
Neurologic conditions affecting the development of claw toes can include:
• Generalized disease of the nerves in the foot (neuropathy)
• Nerve damage from spine disorders
• Residual effects from a prior stroke
• Cerebral palsy
• Severe trauma of the leg in which there is nerve damage and muscle
Symptoms of Claw Toe
Patients with claw toes typically complain about pain as well as the deformity itself. Patients often have generalized pain and callus formation under the ball of the foot, which results from the claw toes pushing down the metatarsal bones.
The toes themselves are crooked and bent, becoming stiff over time. This can cause painful rubbing or calluses at the tips of the toes or on the top knuckle where it rubs in the shoe.
Patients often complain of crowding and difficulty with shoe wear, often stating that even sneakers and comfortable walking shoes still hurt. In some cases, rubbing or pinching on the toes can be severe enough to lead to sores or infection in the toes.
Diagnosis of Claw Toe
The foot surgeon will perform a careful examination of the entire foot and ankle to determine if there are any underlying conditions which may be contributing.
Specifically, your doctor may look for:
• Muscle weakness, imbalance, or tightness of the joints that may suggest underlying problems from spine-related nerve damage or neurologic diseases
• Flexibility or stiffness in the claw toes which may give hints about proper treatment
• Points of maximum tenderness on the foot
• Overall posture or alignment of the foot
• Associated pain or deformity of the big toe adjacent to the claw toes
Standing X-rays of the foot are necessary to identify the presence of underlying arthritis or bony abnormalities. These X-rays can also give the physician an idea as to the severity and degree of the claw toe deformities and overall bone condition to help with planning any treatment choices.
Non-surgical Treatment of Claw Toe
Initial treatments favor non-surgical options in most cases. Patients with claw toe deformities often benefit from wearing comfortable shoes that include a wide toebox and increased depth to prevent rubbing of the toes. A curved sole on the shoe or sneaker — often termed a rocker-bottom sole — can assist with walking and rolling off the foot during gait.
Typically, taping or strapping of multiple toes can be cumbersome and ineffective, particularly if the toes are quite stiff. Instead, the surgeon may recommend simple cushioning or padding of the prominent knuckles to relieve pain and prevent calluses or ulcers. A pad behind the ball of the foot may take pressure off those sore areas, likewise relieving pain.
An alternative is a full-length prescription orthotic insole designed in a similar manner. Patients may have some relief with use of anti-inflammatory medications, particularly if the claw toe deformities result from an arthritis condition. Physical therapy is not routinely effective for these types of toe deformities.
Surgical Treatment of Claw Toe
In cases with severe deformities or if non-surgical methods have failed, surgery may be considered. It is important to determine if the toes are flexible or stiff, which impacts surgical decision making.
If the toes remain flexible, surgery consists of releasing tight or scarred tissue and transferring affected tendons to straighten the toes.
In most cases, however, the toes are relatively stiff and surgery involves bone procedures to remove the affected knuckles and straighten the toes. This often requires placement of metallic pins or wires protruding from the toes to maintain alignment while they heal. The patient often has to wear a specialized type of surgical shoe or boot afterward during recovery. It is also important to surgically correct any associated disorders of the big toe or remainder of the foot at the same time in order to improve the overall odds that the toe surgery will be successful.
After claw toe surgery most patients are able to resume wearing a comfortable walking shoe or sneaker but many have difficulty with tight fitting dress shoes or high heels. Likewise, most patients are able to function well during walking and daily activities but may have limits with more aggressive activities such as running, sports, or standing on tiptoe.