Claw Toe Treatment & Management
- Author: James K DeOrio, MD; Chief Editor: Jason H Calhoun, MD, FACS more...
Medical treatment for claw toes depends on the underlying cause. Therefore, anti-inflammatory drugs, glucose-lowering agents, and antibiotics all may be appropriate. However, these treatments are not believed to reverse the claw toe position.
After medical treatment is initiated, consider conservative therapy, including avoidance of wearing high-heeled, narrow-toed shoes, which increase dorsal ground reactive forces on the toe and crowd the toes against each other, producing impingement. Shoes with a wide toe box, soft upper shoe, and stiff sole to absorb dorsally directed forces against the plantar plate are appropriate. Some high-quality athletic shoes fulfill these criteria.
A metatarsal bar can be added to the shoe to avoid metatarsal pressure, but patients more easily accept metatarsal pads (see the first image below). Cushioning sleeves or stocking caps with silicon linings can relieve pressure points at the proximal interphalangeal (PIP) joint and tip of the toe (see the second image below). A longitudinal pad beneath the toes can prevent point pressure at the tip of the toes.[16, 17]
Because the metatarsophalangeal (MTP) joint is always dorsiflexed by definition, some correction of its position is necessary to restore a more neutral angle at the MTP joint. This consists of Z-lengthening of the extensor tendon, dorsal MTP capsulotomy, and collateral ligament release (see the images below). If deviation is present in the frontal or coronal plane in addition to claw toe, the loose collateral ligament side can be imbricated instead of released.[10, 18, 19, 20, 21]
At the PIP joint (if it is completely flexible), a flexor digitorum longus (FDL) transfer to extensor tendon can bring the toe into alignment. This is accomplished by making a longitudinal cut across the plantar MTP proximal skin crease, retracting the skin with one or two small Meyerding retractors if necessary, splitting the tendon sheath, isolating the FDL tendon between the FDL brevis tendons, passing a small curved hemostat beneath the long flexor to establish tension in the tendon, and then cutting the tendon distally through a small stab incision in the skin just proximal to its attachment (see the images below).
The two distal raphes are held with two hemostats, and blunt separation is accomplished by cutting the distal connecting raphe of the FDL tendon into two parts with tenotomy scissors. Through the dorsal incision used to address the Z tendon lengthening, curved hemostats are directed circumferentially around the proximal phalanx. The tip of the FDL tendon raphe is grasped on the medial side and brought from the plantar wound dorsally. (See the images below.)
A similar technique is used to grab the lateral raphe and bring it dorsally. The tendons are attached to themselves and to the repaired extensor Z-lengthened tendon with 2-0 absorbable suture (see the images below). Absorbable suture prevents the formation of a permanent knot bump on the dorsal aspect of the toe.
The tendon transfer is summarized in the video below.
If the PIP is fixed in flexion or cannot be brought back easily to a neutral position, remove the distal portion of the proximal phalanx along with the articular cartilage of the middle phalanx. If only a PIP resection is required (an FDL transfer is not needed), a shorter longitudinal incision can be made dorsally over the MTP joint and proximal phalanx for the Z-lengthening, dorsal capsulotomy, and collateral ligament release surgery. A transverse incision can then be made at the PIP joint for correction of the fixed deformity. (See the images below.)
If an FDL transfer is necessary along with a PIP resection, this may be accomplished with extension of the dorsal longitudinal MTP incision over the PIP joint. Once through the skin, a continuation of the Z-lengthening of the tendon may be accomplished across the PIP joint. The distal portion of the proximal phalanx is isolated by cutting the collateral ligaments and exposing the bone. The distal portion of the proximal phalanx is cut with a small, sharp bone-cutting device (eg, a saw) just proximal to the flare of the condyles.
The articular cartilage is then removed from the proximal portion of the middle phalanx. A 0.54-mm doubly pointed Kirschner wire (K-wire) is driven into the distal-cut bony surface of the middle phalanx, with care taken to keep the guide wire in the center of the bone to avoid eccentric positioning. The K-wire is brought out of the tip of the toe while the DIP joint is held in neutral position. The K-wire is then grasped distally and drilled back through the proximal phalanx across the metatarsal head, with the interphalangeal joints held in neutral position with slight flexion at the MTP joints (see the images below).[22, 23]
The resected PIP joint is now inspected to avoid eccentricity and bone prominence. If this is found, the prominence is resected or the guide wire replaced. This guide wire, being somewhat larger than the previously recommended 0.54-mm K-wires, is less likely to break, does not become unstable (which would cause infection), and can be left in place for 4 weeks to increase the chance of fusion or fibrosis of the PIP joint.
If the PIP joint is not resected, stabilization of soft tissue at the MTP joint is important to promote ultimate healing in the corrected position. Therefore, a K-wire can be driven from the articular cartilage of the proximal phalanx out of the tip of the toe and back antegrade through the metatarsal head. This can also be attempted retrograde from the tip of the toe, with the toe in a slightly plantar-flexed position at the MTP joint and neutral at the PIP and DIP joints. This is more difficult. However, even if the pin only engages the capsular tissue of the MTP joint, this is often enough to keep the joint relatively stable.
The pin is removed after 2 weeks, because the goal is joint stability, not arthrodesis. The joint may be taped for an additional 4 weeks if further immobilization is necessary.
Almost always, the DIP joint is flexible in a claw toe and is relieved with a flexor-to-extensor transfer. However, should a fixed DIP joint be found, especially if it is part of the problem (ie, pressure on the nail or the tip of the toe), resection of the distal portion of the proximal phalanx and articular portion of the distal phalanx can be performed in a similar fashion to that used on the PIP joint. A pinning technique similar to that described above also may be used.
Sometimes, such chronic dorsal dislocation of the proximal phalanx is present on the metatarsal head that reduction of the proximal phalanx is not possible or, if attempted, leaves an extreme tightness across the MTP joint, resulting in vascular compromise.
In this instance, an osteotomy, from the proximal dorsal articular surface of the metatarsal head in a direction plantar proximal along a plane parallel to the sole of the foot, allows metatarsal head retraction and reduction of the tension in the neurovascular bundle. The dorsal lip of the metatarsal shaft can be removed, and the head is fixed to the remaining shaft with a screw or continuation of the lesser toe pin into the dorsal metatarsal head and then into the center portion of the shaft. This technique is preferable to metatarsal head resection, which can result in a transfer lesion to another metatarsal head.
Forefoot surgery is typically performed in an outpatient setting. A fresh dressing is applied the next day, and stitches are removed after 2 weeks. Arthrodesis pins are removed after 4 weeks, and the other types of pins are removed after 2 weeks. Patients may shower with pins protruding from the toes.
An algorithm to help determine the appropriate surgical procedure and postoperative treatment is displayed in the image below.
The most common complication is pain from recurrent deformity in the sagittal or frontal plane, resulting from inadequate correction of the deformity, failure to obtain an arthrodesis or stable fibrosis, or premature or patient-prompted pin removal.
Other complications include pain from failure of the wound to heal, infection, numbness, dysesthesias, vascular compromise with blistering or eschar formation, and loss of the toe. If pallor of the toe is still present 30 minutes after surgery, the toe is manipulated into a more dorsiflexed position with the pin in place. If the toe does not become pink within 15 minutes, the pin is removed.
Outcome and Prognosis
The experiences of other authors indicate that complete correction of the toe is necessary to achieve the best result. Of course, this presumes careful attention to detail and a toe with normal vascularity.
Taylor and Pyper, via transfer of both the long and short flexor to the extensor hood without bony resection, achieved only 72% and 51% good results, respectively. Pyper also noted that with soft-tissue procedures alone, the deformity recurred and results were somewhat unpredictable. Therefore, Frank and Johnson and McCluskey et al recommend PIP resection along with soft tissue procedures to realign the toe.
Barbari and Brevig reviewed 31 patients who had surgery on multiple toes. These authors concluded that the best cosmetic results were achieved in younger patients, and they noted that active or passive motion in the interphalangeal joints was present in 60% of these cases. Of course, restriction in range of motion is an intended outcome of the procedure. Patients must be aware that in most instances, they will sacrifice prehensile action of the toe for less pain, will have better shoe-wearing capabilities, and, ideally, will have an improved cosmetic result.
Specific disease entities seem to fare similarly; Cyphers and Feiwell reported 60% good results in patients with myelomeningocele.
A prospective multicenter observational study of 117 patients requiring PIP joint realignment who underwent placement of angled intramedullary implants found that implantation resulted in a high rate of fusion and a good outcome. None of the patients with incomplete joint fusion who had a stable joint with no pain required reoperation.
Future and Controversies
A future prospective study that separates claw toes from hammer toes, fixed from flexible, severe from mild, and bony correction (ie, PIP and metatarsal neck osteotomies) from soft-tissue procedures alone is necessary. The addition of an extensor tendon transfer beneath the intermetatarsal ligament with reattachment to the proximal phalanx may help improve continued deformity at the time of surgery or recurrent postoperative dorsiflexion deformity.
When to perform each of the procedures on a claw toe and the extent of the surgical procedure on a single toe remain controversial. Other controversies are a bolster suture above the PIP joint in lieu of a pin, the size of the toe fixation pin, the duration it needs to remain in place, and whether or not it needs to cross the MTP joint.
Coughlin MJ. Lesser toe abnormalities. In: Chapman M, ed. Operative Orthopaedics. Philadelphia, Pa: JB Lippincott; 1988:1765-76.
Coughlin MJ. Lesser toe deformities. Orthopedics. 1987 Jan. 10(1):63-75. [Medline].
Coughlin MJ, Mann RA. Lesser toe deformities. In: Mann RA, ed. Surgery of the Foot and Ankle. 7th ed. St. Louis, Mo: Mosby; 1999:320-91.
Mann R, Coughlin M. Lesser toe deformities. In: Jahss M, ed. Disorders of the Foot and Ankle. Philadelphia, Pa: WB Saunders; 1991:1208-9.
Barnicot NA, Hardy RH. The position of the hallux in West Africans. J Anat. 1955 Jul. 89(3):355-61. [Medline].
Engle ET, Morton DJ. Notes on foot disorders among natives of the Belgian Congo. J Bone Joint Surg. 1931. 13:311-9.
James CS. Footprints and feet of natives of the Solomon Islands. Lancet. 1939. 2:1390-3.
Wells LH. The foot of the South African native. Am J Physiol Anthropol. 1931. 15:185-289.
Scheck M. Etiology of acquired hammertoe deformity. Clin Orthop. 1977 Mar-Apr. (123):63-9. [Medline].
Arnold H. [Lesser toe deformities. Definition, pathogenesis, and options for surgical correction]. Orthopade. 2005 Aug. 34(8):758-66. [Medline].
Marx RM. Anatomy and pathophysiology of lesser toe deformities. In: Foot and Ankle Clinics. Philadelphia, Pa: WB Saunders; 1998:. 199.
Sarrafian SK. Correction of fixed hammertoe deformity with resection of the head of the proximal phalanx and extensor tendon tenodesis. Foot Ankle Int. 1995 Jul. 16(7):449-51. [Medline].
Sarrafian SK, Topouzian LK. Anatomy and physiology of the extensor apparatus of the toes. J Bone Joint Surg Am. 1969 Jun. 51(4):669-79. [Medline].
Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg Am. 1989 Jan. 71(1):45-9. [Medline].
Claisse PJ, Binning J, Potter J. Effect of orthotic therapy on claw toe loading: results of significance testing at pressure sensor units. J Am Podiatr Med Assoc. 2004 May-Jun. 94(3):246-54. [Medline].
Coughlin MJ, Thompson FM. The high price of high-fashion footwear. In: American Academy of Orthopaedic Surgeons, eds. Instructional course lectures. Vol 44. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1995:371-7.
Lutter LD. Sexy shoes or sorry feet. Foot Ankle Int. 2004 Jan. 25(1):1-2. [Medline].
Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg. 1951. 33B:539-542.
Steensma MR, Jabara M, Anderson JG, Bohay DR. Flexor hallucis longus tendon transfer for hallux claw toe deformity and vertical instability of the metatarsophalangeal joint. Foot Ankle Int. 2006 Sep. 27(9):689-92. [Medline].
Lui TH. Arthroscopic-assisted correction of claw toe or overriding toe deformity: plantar plate tenodesis. Arch Orthop Trauma Surg. 2007 Nov. 127(9):823-6. [Medline].
Nakamura S. Temporary Kirschner wire fixation for a mallet toe of the hallux. J Orthop Sci. 2007 Mar. 12(2):190-2. [Medline].
Bayod J, Losa-Iglesias M, Becerro de Bengoa-Vallejo R, Prados-Frutos JC, Jules KT, Doblaré M. Advantages and drawbacks of proximal interphalangeal joint fusion versus flexor tendon transfer in the correction of hammer and claw toe deformity. A finite-element study. J Biomech Eng. 2010 May. 132(5):051002. [Medline].
Pyper JB. The flexor-extensor transplant operation for claw toes. J Bone Joint Surg Br. 1958 Aug. 40-B(3):528-33. [Medline].
Frank GR, Johnson WM. The extensor shift procedure in the correction of clawtoe deformities in children. South Med J. 1966 Aug. 59(8):889-96. [Medline].
McCluskey WP, Lovell WW, Cummings RJ. The cavovarus foot deformity. Etiology and management. Clin Orthop. 1989 Oct. (247):27-37. [Medline].
Barbari SG, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure. Foot Ankle. 1984 Sep-Oct. 5(2):67-73. [Medline].
Cyphers SM, Feiwell E. Review of the Girdlestone-Taylor procedure for clawtoes in myelodysplasia. Foot Ankle. 1988 Apr. 8(5):229-33. [Medline].
Coillard JY, Petri GJ, van Damme G, Deprez P, Laffenêtre O. Stabilization of proximal interphalangeal joint in lesser toe deformities with an angulated intramedullary implant. Foot Ankle Int. 2014 Apr. 35(4):401-7. [Medline].
|Deformity||MTP Joint||PIP Joint||DIP Joint|
|Hammer toe||Dorsiflexed* or neutral||Plantar flexed||Neutral, hyperextended, or plantar flexed*|
|Claw toe||Dorsiflexed||Plantar flexed||Plantar flexed|
|Mallet toe||Neutral||Neutral||Plantar flexed|
|Curly toe||Neutral or plantar flexed||Plantar flexed