Claw Toe Treatment & Management

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

Approach Considerations

Indications for treatment are the presentations previously described that produce pain (see Presentation). [22]  Contraindications for operative treatment include poor vascularity to the toe (including vascular problems that could lead to ischemia and possible need for amputation following surgery, eg, diabetes, atherosclerosis) and poor skin quality. Of course, an open infected wound—for instance, on the proximal interphalangeal (PIP) joint from shoe pressure—should also be resolved prior to surgery.

An algorithm to help determine the appropriate surgical procedure and postoperative treatment is displayed in the image below.

Claw toe. Algorithm to determine appropriate surgi Claw toe. Algorithm to determine appropriate surgical procedure and postoperative treatment.

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 involve the use of a bolster suture above the PIP joint in lieu of a pin, the size of the toe fixation pin, the length of time for which it must remain in place, and whether or not it must cross the metatarsophalangeal (MTP) joint.

There is a need for a prospective study that separates claw toes from hammertoes, fixed from flexible, severe from mild, and bony correction (ie, PIP and metatarsal neck osteotomies) from soft-tissue procedures alone. 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.

Minimally invasive (percutaneous) approaches to treatment of lesser-toe deformities such as claw toe have been associated with high correction potential and low complication rates. [23]  Hedegaard Andersen et al evaluated outcomes of needle flexor tenotomies as a treatment option for hammertoes, mallet toes, and claw toes in 81 patients with diabetes (106 tenotomies); they found needle flexor tenotomies to be safe and effective as compared with scalpel tenotomies done by scalpel, both as treatment for ulcers and to prevent formation of new ulcers associated with these deformities. [24]  Schmitz et al described similar results. [25]

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Medical Therapy

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.

Conservative treatment

After medical treatment is initiated, consider conservative therapy, [26] 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 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. [27, 28]

Pad beneath multiple claw toes to reduce pressure Pad beneath multiple claw toes to reduce pressure at tips.
Claw toe. Silicone cap on second toe and sleeve on Claw toe. Silicone cap on second toe and sleeve on third toe, with sleeve reversed to show silicone inside.
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Surgical Therapy

Because the 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. [9, 14, 29, 30, 31]

Claw toe. Extensor tendon exposure. Claw toe. Extensor tendon exposure.
Claw toe. Z lengthening of extensor tendon. Claw toe. Z lengthening of extensor tendon.
Claw toe. Capsulotomy. Claw toe. Capsulotomy.
Claw toe. Collateral ligament release. Claw toe. Collateral ligament release.
Claw toe. Repaired extensor tendon. Claw toe. Repaired extensor tendon.

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 via the following steps:

  • Making a longitudinal cut across the plantar MTP proximal skin crease (see the first image below)
  • Retracting the skin with one or two small Meyerding retractors if necessary
  • Splitting the tendon sheath (see the second image below)
  • Isolating the FDL tendon between the flexor digitorum brevis (FDB) tendons (see the third image below)
  • Passing a small curved hemostat beneath the long flexor to establish tension in the tendon
  • Cutting the tendon distally through a small stab incision in the skin just proximal to its attachment (see the fourth and fifth images below)
Claw toe. Make longitudinal incision across the pl Claw toe. Make longitudinal incision across the plantar metatarsophalangeal joint.
Claw toe. Split tendon sheath to expose flexor ten Claw toe. Split tendon sheath to expose flexor tendons.
Claw toe. Isolate flexor digitorum longus tendon f Claw toe. Isolate flexor digitorum longus tendon from flexor digitorum brevis, and place it under tension.
Claw toe. Cut flexor digitorum longus tendon just Claw toe. Cut flexor digitorum longus tendon just proximal to its attachment.
Claw toe. Pull flexor digitorum longus tendon loos Claw toe. Pull flexor digitorum longus tendon loose from its attachment.

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. (See the first and second images below.) 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 third and fourth images below.)

Claw toe. Separate 2 raphes of the flexor digitoru Claw toe. Separate 2 raphes of the flexor digitorum longus tendon.
Claw toe. Grasp each side (raphe) of flexor digito Claw toe. Grasp each side (raphe) of flexor digitorum longus tendon with small hemostat.
Claw toe. Make dorsal incision to grasp flexor dig Claw toe. Make dorsal incision to grasp flexor digitorum longus tendon.
Claw toe. Through dorsal incision, curve hemostat Claw toe. Through dorsal incision, curve hemostat around proximal phalanx, avoiding neurovascular bundle, and grasp tip of same-side flexor digitorum longus tendon.

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.

Claw toe. Repair each end of raphe to other raphe Claw toe. Repair each end of raphe to other raphe and split extensor tendon.
Final repair of claw toe. Final repair of claw toe.
Multiple repaired claw toes; Kirschner wires added Multiple repaired claw toes; Kirschner wires added for stability.

The tendon transfer is summarized in the video below.

Claw toe. Video shows flexor-to-extensor tendon transfer with extensor Z-lengthening tenotomy and dorsal capsular release in 54-year-old man with multiple claw toes following brain injury. Toe is pinned with 0.54-mm Kirschner wire just prior to transferring tendon dorsally (not shown in video). Remaining lesser toes, 2 and 4, underwent identical procedure after this video was made. In addition, fifth toe had flexor digitorum longus release with extensor tendon lengthening, and great toe underwent interphalangeal fusion with extensor hallucis longus Z-lengthening.

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 (ie, 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.)

Claw toe. Elliptical outline of skin incision. Claw toe. Elliptical outline of skin incision.
Claw toe. Redundant skin being excised. Claw toe. Redundant skin being excised.
Claw toe. Isolate distal portion of proximal phala Claw toe. Isolate distal portion of proximal phalanx.
Claw toe. Remove distal portion of proximal phalan Claw toe. Remove distal portion of proximal phalanx.
Claw toe. Feather edges of proximal phalanx to ens Claw toe. Feather edges of proximal phalanx to ensure no prominent edges.
Claw toe. Remove articular cartilage of middle pha Claw toe. Remove articular cartilage of middle phalanx.
Claw toe. Drill pin retrograde from middle phalanx Claw toe. Drill pin retrograde from middle phalanx out of tip of toe.
Claw toe. After pin has been drilled back into  pr Claw toe. After pin has been drilled back into proximal phalanx and metatarsal head, repair skin and extensor tendon over proximal interphalangeal joint.

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 distal interphalangeal (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 (IP) joints held in neutral position with slight flexion at the MTP joints (see the images below). [32, 33]

Claw toe. Bent pin at end of toe; proximal incisio Claw toe. Bent pin at end of toe; proximal incision has been used for Z-lengthening of extensor tendon.
Claw toe. Dorsal approach to proximal interphalang Claw toe. Dorsal approach to proximal interphalangeal joint and extensor tendon.
Claw toe. Z-lengthened extensor tendon with end of Claw toe. Z-lengthened extensor tendon with end of proximal phalanx exposed.
Claw toe. Remove distal portion of proximal phalan Claw toe. Remove distal portion of proximal phalanx.
Claw toe. Grasp end of proximal phalanx for remova Claw toe. Grasp end of proximal phalanx for removal.
Claw toe. Remove articular cartilage of middle pha Claw toe. Remove articular cartilage of middle phalanx.
Claw toe. Bone ends of proximal interphalangeal jo Claw toe. Bone ends of proximal interphalangeal joint.
Claw toe. Place wire in middle of proximal phalanx Claw toe. Place wire in middle of proximal phalanx.
Claw toe. Drill wire out of tip of toe, then back Claw toe. Drill wire out of tip of toe, then back through proximal phalanx and metatarsal head.
Claw toe. Toe in straightened position, with dorsa Claw toe. Toe in straightened position, with dorsal incision used to expose dorsal metatarsophalangeal capsule for release.

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 plantarflexed 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 the 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.

When claw toe is due to FDL shortening caused by ischemic contracture of the muscle after posterior leg compartment syndrome, the Valtin procedure (transfer of the FDB to the FDL after FDL tenotomy) may be considered as an option. In a study of 10 such patients treated a mean of 34 months after the injury, Gonçalves et al found that all 10 regained toe flexion and had no claw toe even during ankle dorsiflexion. [34]  

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.

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Complications

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.

When a flexor-to-extensor transfer is done with the tunnel technique instead of the tendon-splitting technique, iatrogenic fracture through the drilled tunnel sute is a possible complication. DiPaolo et al found that such fracture was more likely to occur in proximal phalanges with a bone diameter smaller than 6 mm. [35]  In their study, half of the proximal phalanges fractured with a force of 100-200 N, and the majority of the thinner bones (ie, diameter < 6 mm) fractured with a force of less than 100 N.

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