Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Claw Toes
Claw Toes
Clifford L. Jeng MD
BasicsDescription
The term “claw toes” describes a hyperextension
deformity of the MTP joint of the lesser toes with flexion deformity of
the PIP joint (Fig. 1).
deformity of the MTP joint of the lesser toes with flexion deformity of
the PIP joint (Fig. 1).
General Prevention
Use of appropriate shoe wear (wide shoes with a high toe box) can prevent the development of claw toes in many cases.
Epidemiology
Incidence
-
Increases with advancing age
-
Occurs more frequently in females than males (1).
Genetics
Patients with a hereditary motor sensory neuropathy as
the cause of claw toes may have an autosomal dominant pattern of
transmission.
the cause of claw toes may have an autosomal dominant pattern of
transmission.
Pathophysiology
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The most common cause is an imbalance between the intrinsic and extrinsic muscles of the foot.
-
Concurrent contracture of the long flexors and extensors of the toes without any balancing force from the intrinsic muscles
-
-
Typically occurs secondary to underlying
neurogenic or inflammatory conditions that lead to imbalance of the toe
musculature and attenuation of the passive ligament restraints of the
joints -
Can be idiopathic
Fig. 1. Clinical photograph of claw toe deformity. -
Causative factors:
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Tight shoe wear
-
Hallux valgus
-
Inflammatory arthropathy
-
Neuropathy
-
Diabetes mellitus
-
Hereditary sensorimotor neuropathies
-
Neuromuscular disease
-
Spasticity disorders
-
Compartment syndrome
-
DiagnosisSigns and Symptoms
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Dorsal prominence of the PIP joint of the lesser toes
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Callosities and irritation of the overlying skin
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Pain over the dorsum of the toe or under the ball of the foot (metatarsalgia)
-
Difficulty with shoe wear
History
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Patients may complain of unacceptable
cosmetic appearance, difficulty with shoe wear, or a painful bursa over
the dorsum of the PIP joint. -
With hyperextension of the MTP joint, the
plantar fat pad subluxates distally and causes painful plantar calluses
and possible ulcerations in insensate feet.
Physical Exam
-
Often occurs in multiple adjacent digits, as well as bilaterally
-
Often associated with cavus foot deformity
-
The clinician should:
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Manipulate the joints to determine whether the deformity is rigid or flexible
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Perform a thorough neuromuscular exam
-
Test sensation of the foot
-
Imaging
Plain radiographs show subluxation of the MTP joints and flexion deformity of the PIP joint.
Differential Diagnosis
-
Other conditions have similar signs and symptoms but are not associated with hyperextension of the MTP joints:
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Hammer toes
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Mallet toes
-
TreatmentGeneral Measures
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A Budin splint may help correct flexible deformities.
-
Silicone padding covering the toes may pad the symptomatic areas.
-
Cushioned insoles can protect from painful metatarsalgia.
-
Wide shoes with a high toe box can avoid painful rubbing of the claw toes.
P.77
Geriatric Considerations
-
This condition is very common in elderly females.
-
If morbidities such as diabetes or peripheral vascular disease coexist, surgical management should be a last resort.
Pediatric Considerations
Congenital curly toes may be present at birth and may require tendon releases at an early age.
Surgery
-
For flexible deformities, a flexor-to-extensor tendon transfer can be performed to straighten the claw toe.
-
Rigid deformities require release of the
contracted MTP capsule and collateral ligaments, and extensor tendon
release or lengthening. -
Claw toes with dislocation of the MTP
joint are treated with oblique distal metatarsal osteotomy to achieve
bony shortening and reduce the MTP joint (2,3). -
Rigid PIP joint contractures are corrected with partial phalangectomy or PIP joint fusion.
Follow-upIssues for Referral
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Persistent pain not relieved by nonoperative care:
-
Inability to wear shoes
-
Overlying skin ulceration or impending ulceration in patients with neuropathy
-
Prognosis
Claw toes usually are progressive, worsening in pain and deformity over time.
Complications
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Complications of surgical treatment include:
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Stiffness
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Wound infection
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Persistent pain
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Failure to correct deformity adequately
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Recurrence of deformity
-
References
1. Coughlin MJ. Lesser toe abnormalities. Instr Course Lect 2003;52:421–444.
2. Hofstaetter SG, Hofstaetter JG, Petroutsas JA, et al. The Weil osteotomy: a seven-year follow-up. J Bone Joint Surg 2005;87B:1507–1511.
3. Trnka
HJ, Muhlbauer M, Zettl R, et al. Comparison of the results of the Weil
and Helal osteotomies for the treatment of metatarsalgia secondary to
dislocation of the lesser MTP joints. Foot Ankle Int 1999;20:72–79.
HJ, Muhlbauer M, Zettl R, et al. Comparison of the results of the Weil
and Helal osteotomies for the treatment of metatarsalgia secondary to
dislocation of the lesser MTP joints. Foot Ankle Int 1999;20:72–79.
Additional Reading
Barbari SG, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure. Foot Ankle 1984;5:67–73.
Barouk LS. [Weil’s metatarsal osteotomy in the treatment of metatarsalgia]. Orthopade 1996;25:338–344.
Mizel MS, Yodlowski ML. Disorders of the lesser MTP joints. J Am Acad Orthop Surg 1995;3:166–173.
Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg 1989;71A:45–49.
Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg 1951;33B:539–542.
MiscellaneousCodes
ICD9-CM
735.5 Claw toe
Patient Teaching
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Many splints and pads can be obtained at local drugstores in the foot care section.
-
Medical supply stores may have a wider selection of orthoses.
Prevention
Avoidance of narrow, tight-fitting shoes is the best way to prevent the development of claw toes.
FAQ
Q: What differentiates claw toes from hammer toes?
A:
Claw toes involve flexion contractures of the distal and PIP joints
along with hyperextension of the MTP joint. Hammer toes involve
isolated PIP flexion deformity.
Claw toes involve flexion contractures of the distal and PIP joints
along with hyperextension of the MTP joint. Hammer toes involve
isolated PIP flexion deformity.
Q: What is the most common underlying etiology of claw toes?
A:
Neurologic disorders cause atrophy or weakness of the intrinsic muscles
of the foot. These conditions lead to relative imbalance between the
intrinsic and extrinsic muscles, leading in turn to flexion deformities
of the IP joints and hyperextension of the MTP joint. Claw toes
commonly are seen in conditions such as diabetes (neuropathy), spinal
disorders, stroke, paralysis, and spasticity disorders, and in
hereditary motor sensory neuropathies such as Charcot-Marie-Tooth
disease.
Neurologic disorders cause atrophy or weakness of the intrinsic muscles
of the foot. These conditions lead to relative imbalance between the
intrinsic and extrinsic muscles, leading in turn to flexion deformities
of the IP joints and hyperextension of the MTP joint. Claw toes
commonly are seen in conditions such as diabetes (neuropathy), spinal
disorders, stroke, paralysis, and spasticity disorders, and in
hereditary motor sensory neuropathies such as Charcot-Marie-Tooth
disease.