Claw Toe Clinical Presentation

Updated: Feb 05, 2021
  • Author: James K DeOrio, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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Presentation

History

Patients with claw toe deformities can present with a variety of symptoms related to the position of the toe. Patients most often report pain at the dorsal proximal interphalangeal (PIP) joint from an impingement of the toe on the shoe. A callus or erythema is present over the dorsal PIP joint where it abuts the shoe. Patients also may report pain at the tip of the toe from pressure against the point of the distal phalanx. [21]

Patients can have a callus at the tip of the toe and a malformed nail, especially patients with diabetes and neuropathies (see the image below). When pain beneath the callus exceeds the neuropathic threshold in a patient with diabetes, an abscess may be present beneath the callus, which is discovered only when the callus is debrided. The other source of pain is the metatarsophalangeal (MTP) joint, which develops synovitis because of irritation from its extended position and instability.

Callus at tip of second claw toe. Callus at tip of second claw toe.

Another less often seen presentation is impingement of the lateral claw toe on the adjacent toe, causing a callus or soft corn on the medial border of the claw toe. This is usually secondary to clawing of the fourth or fifth toe. Finally, the relative increased pressure beneath the metatarsal head from the inability of the toe to share in weightbearing can result in metatarsalgia. This occurs secondary to distal migration of the plantar fat pad with hyperextension of the MTP joint.

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Physical Examination

Assessing claw toe primarily consists of a physical examination, with additional tests as required. With the patient sitting, each of the three joints (MTP, PIP, and distal interphalangeal [DIP]) is tested for flexibility in the sagittal plane and stability in the frontal and sagittal planes. Vascularity of the toe is assessed clinically, and the presence of calluses or erythema is duly noted.

Normal sensation can be determined by the patient's ability to feel a 0.5-g force with a monofilament pressure device. If the patient cannot detect a 10-g force applied with a monofilament pressure device, this indicates loss of protective sensation.

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