Introduction

Claw toe and hammertoe conditions are fairly common in cultures that wear shoes. In most cases, these problems can be traced directly to ill-fitting shoes.

Anatomy

The four smaller toes of each foot contain three bones (phalanges) and three joints. The first bone (moving outward from the foot) is called the proximal phalanx, next comes the middle phalanx, and the last is the distal phalanx. 

The metatarsal phalangeal joint (MTP joint) is the first joint that connects the toe to the foot. The second is the proximal interphalangeal joint (PIP joint), and the last is the distal interphalangeal joint (DIP joint). A joint capsule made of ligaments surrounds each joint and holds the bones together. Two tendons run along the bottom of each toe allowing us to curl our toes, and one tendon runs along the top, which raises the toe.

With hammertoe deformity, the last joint of the toe (PIP joint) bends down too much. A claw toe deformity is a combination of a hammertoe deformity plus a bending backward of the first joint of the toe (MTP joint).

Causes

Wearing a shoe that is too short can cause claw toe and hammertoe. In many people, the second toe is actually longer than the big toe, and if shoes are sized to fit the big toe, the second and maybe even the third toe will have to bend to fit into the shoe. Pointed shoes with high heels constantly pushed the foot downhill crowding the toes.

Symptoms

Eventually, toes that are crowded day after day become fixed in that position and will not straighten out. When this occurs, pressure builds in three places:

• At the end of the toe
• Over the PIP joint
• Under the MTP joint

Painful calluses develop as a result of pressure from the shoe.

Diagnosis

Diagnosis of these two conditions comes from the physical exam. In some cases, the doctor may check to make sure no other nerve problems are to blame for the condition, and special tests may be ordered.

Treatment

Conservative Treatment

Treatment depends on the stage of the deformity process. Early in the process, switching to shoes that fit properly may stop the deformity returning the toes to a more normal condition.

If the condition is more advanced, and the toes will not completely straighten, a contracture may exist. A contracture occurs when scar tissue tightens a joint and keeps it from moving through its normal range of motion. Pressure points and calluses caused by a contracture can be treated by switching to shoes with more toe room or by placing pads over calluses to relieve the pressure.

Surgery

If conservative treatments fail, surgery may be needed to correct toe alignment. The procedure performed for claw toe or hammertoe is a reconstruction of the joint (arthroplasty). 

For the hammertoe deformity, an arthroplasty of the DIP joint may be suggested. This procedure is performed through a small incision in the top of the toe over the DIP joint. Once the joint is entered, one side of the joint is removed. This releases the tension on the ligaments and tendons around the joint and allows the toe to be realigned in the proper position. Once the toe is in the proper position, it is held with sutures (stitches) or a metal pin while it heals.

The most common procedure to correct claw toe deformity is an arthroplasty of the PIP joint. In this procedure, an incision is made over the joint. Once the surgeon can see the joint, the end of the proximal phalanx is removed shortening the toe and relaxing the contracture around the joint. The toe is then either held in the straight position until it heals with metal pins or sutures.

As the joint heals, scar tissue forms, connecting the two bones together and replacing the area where the joint once was. Surgeons refer to this as a false joint (or pseudo joint) because the scar tissue allows a bit of motion to occur between the two bones while keeping them from rubbing together and causing pain.

If clawing is a problem, then the MTP joint may also need to be released relieving the contracture of the joint and moving the proximal phalanx into the correct position. This procedure is performed by making an incision on the top of the toe over the MTP joint. The surgeon then releases the tight ligaments and tendons until the toe easily moves back into the proper alignment. The toe may be held in proper alignment with a metal pin until it heals. The pin may remain in place for three or four weeks.

Rehabilitation

After surgery, you will usually be fitted with a "post-op shoe." This shoe has a stiff, wooden sole that protects the toes by keeping the foot from bending. If metal pins have been used, they are usually removed after three to four weeks.

You will probably wear a bandage or dressing for about a week following the procedure. The stitches will be removed ten to fourteen days following the procedure. If your surgeon chooses to use dissolvable sutures, they will not need to be removed.