Claw Toes/Hammer Toes

What it is

A claw toe is a condition where the toe looks like a claw. This appearance is caused by the bending or curling downward of the middle joint (PIP) and the tiny joint at the end of the toe (DIP). In addition, the joint where
the toe meets the foot (MTP joint) is cocked up.

Some common causes of claw toes are:

  • Shoes. Claw toe often results from wearing a shoe that’s too short because there is not enough space for the toes. Pointed, high-heeled shoes make matters worse. Combine pointed shoes with high heels, and the foot is constantly being pushed down into a wall, with the toes squished like an accordion.
  • High arches. Some people with high arches also have claw toes.
  • Muscle imbalance. Sometimes the deeper toe muscles are weaker than the surface muscles of the toes because of a nerve problem or a previous injury. For instance, claw toe is sometimes the result of nerve damage caused by diseases like diabetes or alcoholism which can weaken the muscles in your foot. Subtle muscle imbalances occur as we age; this is why clawing of the lesser toes (toes other than the big or great toe) becomes more common in middle-aged and elderly people.

Why it’s a problem

Claw toe deformities are usually flexible at first but, over time, they stiffen and become more rigid. Eventually, toes become fixed in a crooked position and won’t straighten. When this occurs, pressure builds at the end of the toe, over the top (PIP joint), and under the ball of the foot (MTP joint). The increased pressure to these areas causes the skin to thicken. The thickened dry skin is called a callus or corn. As the callus becomes larger it acts like a stone in the shoe, creating more pressure and thus more pain. This is why people with claw toes need shoes that have extra room in the toebox and specific modifications that help decrease the pressure over the calluses. It is not uncommon for people with claw toe to have a hard time finding shoes that are comfortable to wear. It often helps to shave down the calluses with a pumice stone which, in turn, decreases the pressure on the painful area.

Obtaining a metatarsal pad or an orthotic with a metatarsal pad can help decrease the pain you may be feeling in the ball of your foot. If you try these devices, it is very important that their usage in a shoe does not crowd the toebox or make your forefoot (front part of the foot, including toes) feel tight inside the shoe, for this will worsen your symptoms. The best way to ensure a proper fit is to obtain a metatarsal pad and/or an orthotic beforehand, then fit it inside shoes when you’re trying them on.

Surgical treatment

Outpatient or hospital stay: Almost always outpatient (home same day)
Type of anaesthesia: May be regional or general, or a combination
Length of surgery: Depends on the number of toes to be corrected
Recovery time: 6 weeks (to pin removal) for normal walking, up to 6 months for vigorous activity

If wearing proper shoes and orthotics does not alleviate your pain then surgery may be required. The goal of surgery is to correct the deformity. There are many ways to correct a claw toe. How much surgery is required is often determined by the extent and rigidity of the deformity. The more crooked and stiff the toe, the more surgery is required.

The surgeon starts by releasing the tight tendons and ligaments. If the toe can be straightened after the soft tissue release then no further surgery is required. If, however, the toe remains crooked after the soft tissue release then the surgeon will cut the bone to properly realign the toe. After the toe is straight the surgeon will often use a pin to hold the bones and joints in place. The pin often can be seen at the end of the toe.

Recovery

Following surgery:

    • You may have a bandage or dressing to protect the incision for about 1 week.
    • You will be instructed on caring for your dressings, and if and how much weight you can bear on the foot.
    • You may wear a special post-operative shoe with a stiff sole that protects the toes by keeping the foot from bending, or removeable cast.
    • Avoid bending the toes – excessive movement can break the pins.
    • Keep your dressings dry (place a plastic bag on your foot when showering).
    • Watch for complications. Alert your surgeon or visit an emergency room if you experience bleeding that won’t stop, pain that does not subside with prescribed medication, swelling that worsens (or dressings that become too tight – remove them, but visit an emergency room immediately following) after the second day, drainage from the wound, and/or have a fever higher than 38°C or 101°F.

The stitches are generally removed in 10 to14 days. The pins are usually removed after the bone begins to mend, typically in about 4 to 6 weeks. It is common to still have swelling 4 to 6 months post-surgery, but it will eventually resolve.

Pin site care is important

Avoid soaking your foot in water such as a bathtub, swimming pool or hot tub which can cause infection. (If the infection does not resolve with appropriate antibiotics, then the pin may have to be removed.) Your surgeon will instruct you on routine care of the exposed pin sites which may vary from daily cleansing or leaving the post-surgery dressing untouched. If the toe becomes red, hot, swollen, and/or starts draining fluid, see the surgeon or go to the nearest emergency department for assessment.