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A claw toe is a lesser toe with dorsiflexion of the proximal phalanx on the lesser
metatarsophalangeal (MTP) joint and concurrent flexion of the proximal interphalangeal (PIP) and
distal interphalangeal (DIP) joints (see the images below).
Claw toe.

Claw toe is distinguished from hammer toe by the combined dorsiflexion of the MTP joint and
plantar flexion of the DIP joint in claw toe (see the image below). In contrast, a hammer toe may
have some hyperextension at the MTP joint or some flexion at the DIP joint, but it does not have
both concurrently. Typically, the DIP joint is extended in a hammer toe.

Claw toe. Plastic model of hammer toe.

Hammer toe is differentiated from curly toe, which has combined plantar flexion of all three joints
(see the first image below) and from a mallet toe, which has a neutral position of the MTP and PIP
joints and flexion at the DIP joint (see the second and third images below). Clawing often affects
multiple toes (see the fourth image below).[1, 2, 3, 4] Table 1 contains descriptions of lesser toe

Claw toe. Curly toe.

Claw toe. Mallet toes 3 and 4.
Claw toe. Mallet toe.

Multiple claw toes.

Table 1. Lesser Toe Deformities (Open Table in a new window)

MTP Joint

PIP Joint

DIP Joint

Hammer toe

Dorsiflexed* or neutral

Plantar flexed

Neutral, hyperextended, or plantar flexed*

Claw toe


Plantar flexed

Plantar flexed

Mallet toe



Plantar flexed

Curly toe

Neutral or plantar flexed

Plantar flexed

Plantar flexed



The prevalence of claw and hammer toe deformities ranges from 2-20%, gradually increasing with
advancing age. Therefore, claw toe is most often seen in patients in the seventh and eighth
decades of life. Women are affected 4-5 times more than men.
Most people have no underlying disease responsible for the claw toe deformity, but it can occur in
association with neuromuscular diseases, such as multiple sclerosis,Friedreich ataxia, CharcotMarie-Tooth disease, cerebral palsy, mild dysplasia,stroke, and lumbar nerve root impingement.
Metabolic diseases, such as diabetes and inflammatory arthropathies (eg, rheumatoid arthritis,
psoriasis), can also be accompanied by claw toe deformity.
Claw toe deformity results from altered anatomy or neurologic deficit that leads to an imbalance
between the intrinsic and extrinsic musculature to the toes.[9, 10]
The extensor tendon crosses and is held over the MTP joint by an aponeurotic band of fibrous
tissue. Although it does not insert into the proximal phalanx, it is able to dorsiflex the proximal
phalanx of the MTP joint through this aponeurotic band, which goes around the MTP joint and is
inserted onto the plantar plate (see the image below).

Claw toe. Extensor tendon connecting with

extensor hood.
The extensor tendon splits into three parts over the proximal phalanx. The central slip attaches
itself to the dorsal aspect of the base of the middle phalanx. The medial and lateral slips rejoin
distally to insert on the dorsal aspect of the base of the distal phalanx (see the image below). The

extensor tendon is only capable of extending the PIP and DIP joints when the MTP joint is in
neutral flexion; otherwise, this is accomplished by the intrinsic musculature.[11, 12, 13, 14]

Claw toe. Extensor tendon splits into 3 parts

The intrinsics are made of the lumbricals, which are strong extenders of the PIP and DIP joints by
virtue of their attachment onto the extensor sling and the interossei. Interossei are weak extensors
of the interphalangeal joints because so few fibers reach the extensor sling. Furthermore, when
the MTP joint is hyperextended, the lumbrical power in extending the PIP and DIP joints is reduced
because of a mechanical disadvantage.
The flexor digitorum longus (FDL) tendon inserts into the plantar aspect of the distal phalanx, and
the flexor digitorum brevis inserts onto the middle phalanx. Thus, no major antagonist to
dorsiflexion of the proximal phalanx is present. Hence, when the proximal phalanx dorsiflexes,
static tightening of the flexors occurs, which subsequently flexes the PIP and DIP joints.
Stabilization of the lesser MTP joint comes from the static restraint of the plantar plate and the
collateral ligaments.
The collateral ligaments have been reported as the primary stabilizers of the lesser MTP joint. The
two sets of collateral ligaments both emanate from the lateral metatarsal head. The phalangeal
collateral ligament inserts into the proximal phalanx, and the accessory collateral ligament inserts
onto the plantar plate. The plantar plate is attached from the base of the proximal phalanx to an
origin on the metatarsal head, just proximal to the plantar articular cartilage.
When the collateral ligaments and plantar plate lose resiliency or are stretched through repetitive
dorsal directing forces on the proximal phalanx from ground reactive forces, the proximal phalanx
dorsiflexes. Without a strong plantar flexor attached to the proximal phalanx, the proximal phalanx
remains in dorsiflexion, and the PIP and DIP joints subsequently flex (see the image below).

Claw toe. Plantar plate stretches out, and

proximal phalanx is dorsiflexed.

When the flexed position of the PIP and DIP joints remains constant, the collateral ligaments
fibrose along the sides of the PIP and DIP joints, and the position of their joints becomes fixed.
When this occurs, the claw toe deformity becomes rigid, whereas previously it was considered
flexible. This separation of flexible and rigid most often occurs at the PIP joint.
Physical examination
Assessing claw toe primarily consists of a physical examination, with additional tests as required.
With the patient sitting, each of the three joints (MTP, PIP, and DIP) is tested for flexibility in the
sagittal plane and stability in the frontal and sagittal planes. Vascularity of the toe is assessed
clinically, and the presence of calluses or erythema is duly noted.
Normal sensation can be determined by the patient's ability to feel a 0.5-g force with a
monofilament pressure device. If the patient cannot detect a 10-g force applied with a
monofilament pressure device, this indicates loss of protective sensation.
Indications for treatment are the presentations described in Clinical that produce pain.
Relevant Anatomy
See Pathophysiology.
Contraindications to 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 PIP joint from shoe pressure, should also be resolved prior to surgery.
Laboratory Studies
Depending on the clinician's diagnostic considerations, the following laboratory tests may be
Fasting glucose to rule out diabetes
Sedimentation rate to determine the possibility of an underlying infection
Rheumatoid factor
Imaging Studies
Radiographs are obtained to determine or exclude the following:
Arthritic changes from old fractures or inflammatory arthropathies
Increased MTP joint space from synovitis

Osteomyelitis at the tip of the toe from an abscess with a callus

Position of the toes
Other Tests
Vascular pressure measurements, including ankle-brachial indices and absolute toe pressures,
are helpful for the following reasons:
To assess toe viability
To determine whether the toe might reasonably be expected to heal following surgery
Electromyography findings provide information regarding the origin of the claw toe deformity and
whether the patient has a neuropathy.
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, 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 proximal interphalangeal (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.[16, 17]
Pad beneath multiple claw toes to reduce pressure at tips.
Claw toe. Silicone cap on second toe and sleeve on third toe, with sleeve reversed to show silicone inside.
Surgical Therapy
Because the metatarsophalangeal (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 Zlengthening 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.[10, 18, 19, 20, 21]
Final repair of claw toe.

Multiple repaired claw toes; K-wires added for stability.

Claw toe. The movie shows a flexor-to-extensor tendon transfer with an extensor Z lengthening tenotomy
and dorsal capsular release in a 54-year-old man with multiple claw toes following a brain injury. The toe is
pinned with a 0.54-mm Kirschner wire just prior to transferring the tendon dorsally (not shown in movie).
The remainder of the lesser toes, 2 and 4, underwent an identical procedure following the making of this
movie. In addition, the fifth toe had a flexor digitorum longus release with extensor tendon lengthening and
the great toe underwent an interphalangeal fusion with an 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 (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.)
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 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 joints held in neutral position with slight flexion at the
MTP joints (see the images below).[22, 23]
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 plantar-flexed 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 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.
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
An algorithm to help determine the appropriate surgical procedure and postoperative treatment is
displayed in the image below.

Claw toe. Algorithm to determine the appropriate surgical procedure and postoperative treatment.
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
Surgery can be performed under local or regional block, and in appropriate patients, it can be
performed on an outpatient or day-surgery basis.
Surgical therapy includes the following options[5] :
Flexor tenotomy, possibly including plantar capsular release and pinning
Condylectomy and fusion of the middle to distal phalanx
Partial or complete amputation of the distal phalanx (occasionally indicated)
A flexible mallet toe is best treated with a flexor tenotomy. A fixed deformity requires a
condylectomy. An ulcerated or infected toe would do best with a terminal Syme amputation.[6]
Tenotomy is performed by making a small lateral or medial incision over the distal end of the
middle phalanx. The author prefers to visualize the tendon sheath directly by retracting the skin
with double skin hooks or a Ragnell. The sheath is incised longitudinally, and the tendon is hooked
with a small arthroscopic probe. The tendon then can be divided under direct vision.
If some residual contracture is present, the plantar capsule can be stripped of the phalanx with a
Freer dissector. A 1.1 Kirschner wire (K-wire) can be used to immobilize the joint in the neutral
position.[7] One skin stitch or Steri-Strip is used to close.
Distal interphalangeal (DIP) joint fusion is carried out by excising a small ellipse over the dorsal
aspect of the joint, including the extensor. The bone ends are excised, and pinning is carried out.
The skin and extensor are closed in one layer.[8]
Amputation is usually performed as a terminal Syme procedure. The nail bed and the terminal half
of the phalanx are excised.
Postoperatively, routine dressings are applied. The patient can mobilize weightbearing in a
postoperative shoe. Elevating the limb for the first 5-7 days reduces postoperative swelling.
Sutures are removed at 10-14 days. Pins are usually removed at 4 weeks.

Hammer Toe
The flexibility of the deformity determines which technique is appropriate for correction. A flexible
deformity of small magnitude may be amenable to a flexor tenotomy. No more than a small flexion
deformity of the PIP joint should be present, with no subluxation of the MTP joint. A flexible
deformity of greater magnitude requires a Girdlestone-Taylor flexor-to-extensor tendon transfer.
[4] This method functions in the same way as taping or strapping a flexible hammertoe. Pin
fixation is necessary for 4-6 weeks after surgery.
A fixed deformity requires at least resection arthroplasty of the PIP joint.[5] The goal is to shorten
the toe and thereby decrease the deforming forces of the contracted soft tissues. As the
magnitude of the deformity increases, additional procedures, such as flexor tenotomy, extensor
tenotomy, MTP joint release or arthroplasty, and metatarsal shortening may be necessary. Pin
fixation is necessary for 4-6 weeks after surgery.[6, 7, 8]
MTP arthroplasty includes resection of 2 mm of the metatarsal head articular surface and pinning
of the toe across the MTP joint. The resulting arthrofibrosis is theorized to stabilize the MTP joint.
Plantar condylectomy of the metatarsal head may have to be added for plantar metatarsal head
pain without instability or synovitis. Plantar condylectomy with pinning across the MTP joint helps
reduce plantar prominence; the prominence may cause pain or callus over the second metatarsal
head. Removing the condyles results in a bleeding cancellous bone surface on which the
attenuated plantar plate readheres and contracts to stabilize the MTP joint.
MTP plantar plate reconstruction is a more anatomic stabilization of the MTP joint. Reconstruction
of the plantar plate is an increasingly popular popular addition to metatarsal shortening when MTP
instability is present.[9]
Metatarsal-shortening procedures are most likely to be effective in a foot with a long second
metatarsal when second hammertoe is accompanied by pain or plantar callus over the second
metatarsal head or when MTP instability and synovitis are present. To achieve adequate
correction, it may be necessary to combine other procedures (PIP resection arthroplasty,
Girdlestone-Taylor flexor-to-extensor tendon transfer) with the metatarsal shortening. If MTP
instability is present, then plantar plate reconstruction should be added.
PIP joint arthrodesis has been described and is currently performed with regularity.[10, 11] Cockup
deformity is a frequent complication, especially when significant MTP hyperextension is present
Special consideration is necessary when hallux valgus accompanies second hammertoe deformity.
Even if the hallux valgus and bunion are asymptomatic, hallux valgus correction is necessary to
minimize the risk of recurrence of the second hammertoe.
When rotational deformity accompanies hammertoe deformity, rotational or angulatory deformity of
the involved phalanx may be necessary.
Resorbable pins have been considered for hammertoe correction fixation to avoid the necessity of
pin removal in the office. Their strength in this application has not yet been rigorously studied, but
success with resorbable pins and screws for other forms of foot and ankle surgery is encouraging.

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