Claw Toe Deformity
An Overlooked Cause of Foot Pain
Most people are familiar with hammer toes and the painful “corns” they form over the top of the affected toes. However, their distant cousin, the claw toe, is rarely mentioned in most online searches dealing with digital deformities. This, in spite of the fact that they can lead to foot pain that can affect most of the forefoot area. This article will describe exactly what this deformity is, its symptoms and how to treat it.
So what is a Claw Toe?
It’s a bending in the downward direction of the last two joints of a toe like a claw. We have two types of tendons at work in our feet. There are extensors, which are found on the top (dorsal) surface of our feet and are responsible for pulling up or lifting our feet during gait. The second is the flexors which are located on the bottom (plantar) aspect of our feet are responsible for pushing down and helping our feet purchase the ground during gait or standing. These tendon groups must work simultaneously in order to provide a balanced gait. A claw toe deformity occurs when there is an imbalance in our gait or step that causes the flexor tendons to “overwork.”
Therefore over powering the extensor tendons and causing the downward tight “claw like” bend of the middle and last joints of the smaller toes, 2 through 5.
What causes a Claw Toe?
Claw toes, like most other foot deformities, can be caused be genetics, or the foot type we inherit from our parents, the most inherited being a high arched foot known as a cavus deformity. However, most significantly to physicians is that it is mostly are caused by neurological systemic diseases such as: diabetic neuropathy, alcoholic neuropathy, Charcot-Marie -Tooth Disease, spinal cord tumors, Polio, Cerebral Palsy and strokes. Trauma to the spinal cord can also lead to claw toe deformities. The deformity is staged as either rigid, or flexible in nature. The rigid stage implying that the toe will not straighten out in any amount when inside a shoe or even a sandal.
What are the symptoms of a Claw Toe?
A claw toe deformity causes moderate to severe burning sensation on the tips of the lesser digits, 2 to 5 with any shoe wear. It can manifest itself first in one foot or in both at the same time. The pain many times radiates to the bottom of the forefoot. Therefore, making it difficult for the patient to really know where the pain is originating from. There are many cases of claw toe deformities that have been misdiagnosed as metatarsalgia, capsulitis and even tendinitis of the forefoot area.
The more rigid stage of a claw toe deformity, can lead to the formation of very thick and painful calluses on the tip of the the affected toes due to repetitive friction of shoe wear. These calluses can eventually lead to the formation of ulcerations due to that constant friction. This can be very dangerous for patients with diabetes who have difficulty in healing due to poor circulation.
Patients with neuromuscular diseases such CMT have the same risk of forming ulcerations , but can also have their gait seriously compromised due to the pain, even with the use of a brace.
How do we treat Claw Toes?
Most of the patients that come seeking my care for their claw toes have already exhausted every over the counter remedy out there including inserts, pads, pain creams, etc. This is one of those conditions that usually does not respond to conservative care.
So what is the goal of our treatment plan?
We want to correct the deformity and provide the proper orthosis, shoe wear or bracing (if the patient doesn’t already have them) necessary in order to control the disease that lead to the formation of the deformity. This is one of the very few conditions in which I usually skip all conservative treatment options and jump straight into surgical correction. My procedure of choice is a flexor tenotomy, or lengthening of the tight contracted tendon. This is an office based procedure, done using a little local anesthetic to numb the digit. Then the tenotomy of the tight flexor tendon is achieved through a tiny stab incision through the base joint of the toe, using not a scalpel but an 18 gauge syringe needle. The incision is very tiny and usually doesn’t require sutures to close. The deformity is then manually corrected by passively straightening the toe out into the ideal position. The toe is then bandaged in this corrected position so that it heals nice and straight. The patient is able to wear normal shoe wear and resume normal activities within 7 days. The advantages to this procedure are that there is no cutting of bone, it’s minimally invasive and therefore not painful and offers a permanent correction to the deformity.
Surgery as the first and only choice treatment for compromised patients such as diabetics?
Most patients pose this question to me following their clinical evaluation. It’s a fair question given the fact that this deformity is caused by these serious systemic diseases. So let’s address this issue using diabetes as an example. As I mentioned before , this deformity leads to painful thick calluses that can eventually form ulcerations in patients. An ulceration of this type in a diabetic can quickly reach the bone on the tip of the digits, leading to gangrene and possible digital amputation. Once a diabetic looses a single digit to amputation. They are 45% more likely to have a below the knee amputation due to additional stress placed on the other digits.
The highest risk diabetic patients face is in the length of time it takes for these issues to be resolved. With surgery, diabetic patients with ulcerations on the tip of their toes resolve their ulcerations within 3 weeks of having this procedure performed. The procedure is not contraindicated in these patients since it is minimally invasive and most importantly, guarantees that the pain or the callus (ulcer) will not return. This simple and effective procedure is definitely the best choice.