What Are Claw Toes?
A claw toe is a toe that is experiencing significant problems associated with the PIP and DIP joints, which are the joints in the middle of the toe and at the end of the toe, respectively. In full medical terminology, the joints affected are the proximal interphalangeal joint and the distal interphalangeal joint, hence the abbreviations PIP and DIP.
In the condition known as claw toe, the PIP and DIP joints are in a condition of over contraction, which leads them to curl themselves into an arch that somewhat resembles a claw. The name of this condition, therefore, is fairly descriptive of its outward visual appearance. Claw toe can occur in any toe and can occur in multiple toes at once. However, the two most central toes of the body, the so-called "big toes" are usually the ones that suffer the greatest degree of curling when claw toe is present.
Because the joint is so severely contracted when claw toe is present, patients experience a high degree of both pain and pressure in the joint. At times this pain and pressure may reach severe levels. The discomforts associated with claw toe are not merely on account of the internal structure of the toe causing pain to the patient. A related problem is that when patients suffering from claw toe wear shoes, the top surface of the toe is likely to be pressed up against the underside of the top surface of the shoe. This position would be uncomfortable in any case, but walking exacerbates it. The toe will rub back and forth against the shoe, which can lead to blistering and calluses.
At the same time, the end of the toe will be awkwardly pushed against the bottom of the shoe, another unaccustomed position. Because of these factors, those suffering from claw toe may find themselves reluctant to walk or run, which can lead to problems in both lifestyle and other health issues as a large avenue of exercise is neglected.
Although it may seem logical that the muscle is contracting when claw toe is present, the actual problem rests more in the tendons and ligaments of the affected toe. The characteristic downward curl associated with claw toe is a result of the ligaments and tendons being too tight and causing the toe as a whole to contract.
Types of Claw Toe
There are two major divisions in the diagnosis of claw toe:
A rigid claw toe lacks the ability to produce a normal range of motion and in fact is sometimes characterized by the patient being unable to move it at all, whether by internally-based efforts or external manual manipulation. When movement is possible, it will be extremely limited and can become excruciating.
Patients with the condition of a rigid claw toe and quite logically motivated to avoid any movement which produces a significant level of pain; they will therefore adjust their range of motion and angle of movement to levels which are more comfortable. At times this leads to the patient putting more pressure than usual on the ball of the foot in order to spare the toes. This can lead to problems of its own, such as calluses and corns and will probably also be painful.
Flexible claw toe is a less severe condition. When a patient has flexible claw toe, it is possible to straighten the toe by applying external manual pressure. Patients are likely to find that this procedure produces significant discomfort, but at least afterwards, the toe will not be rubbing awkwardly against the wrong surfaces on the inside of the shoe – not while it can still be maintained in a straightened alignment.
Symptoms of Claw Toe
The primary symptom present in patients who are suffering from claw toes is the characteristic curling of one or more toes themselves. The curling can actually take two forms:
- the toe curls downward from the middle joints toward the sole of the foot
- the toe curls bends upward from the joints at the ball of the foot.
Both these forms of curling can resemble the cramped joint appearance that is commonly associated with arthritis, whether or not arthritis can be counted among the cause of the claw toes in an individual patient.
Secondary symptoms sometimes develops as a result of the toe's curled position. Foremost among these are corns and calluses that can appear on the top of the affected toes and sometimes also under the ball of those toes, depending on how the foot has been forced to rub or scrape against the inside of the patient's shoe.
Causes of Claw Toe
Although claw toe is primarily a problem of the tendons and ligaments in the DIP and PIP joints, the underlying cause does involve the related muscles in this area of the body. In short, claw toe is caused by an imbalance in these muscles. When these muscles are not working together with any degree of efficiency and cooperation, the imbalance causes tendons and ligaments to over tighten, becoming unnaturally contracted and pulling the toe into the characteristic clawed position.
An imbalance in the toe muscles, however, is not the only thing that can cause toes to curl downwards and take on the typical appearance of claw toe. Other degenerative foot conditions can lead to deformations in the appearance of the front of the foot, including the toe area. Arthritis, whether it be the juvenile variety or the osteo arthritis often acquired in old age, can also lead to the condition of claw toes.
Other causes of claw toes includes the underlying condition of pes planus, also known as "flat feet." Because those with flat feet may develop walking habits to compensate, the toes can become affected and begin to curl. Serious injuries of the foot are also responsible in some cases for the development of claw toes over time.
If claw toe is not treated, it can become a permanent condition.
Treatment Options for Claw Toe: Footwear and Inserts
One of the most important things that claw toe sufferers can do is to wear shoes that are appropriate for the condition. In most cases this will involve changing to a new style of footwear. Women who have been wearing "fashionable" shoes, particularly those with a very tight fit, will likely find the change to be a radical one, but it is an essential first step in both treatment and prevention of future occurrences.
What type of footwear, then, is most appropriate to wear in order to alleviate the symptoms of claw toes and prevent future recurrences of the problem? The most important characteristic to look for is the roominess of the "toe box." This refers to the area of the shoe intended to enclose or hold the toes. The ideal shoe for claw toe sufferers will possess a toe box that is both wide and tall. In no case should the toe box cause a claw toe sufferer to have to cram his toes into it – there should be sufficient room for the toes, even when they are curled downward into the clawed position.
By making sure that the toe box is both wide and tall, the front of the shoe will not compress the claw toes, but it will also allow them room to move without rubbing against the interior surface of the shoe. By reducing friction, the change of corns, calluses, and blisters developing is also reduced.
Other steps can be taken to adjust the interior environment of the shoe in order to alleviate the pain and awkwardness of having claw toes. Among these are products that are inserted into the shoe in order to hold the toes in a better position. Hammer toe splints and toe crests serve to press downward on the claw toe, encouraging it to lie in a more supine position. This provides some relief and allows patients to walk with a more normal gait, thereby reducing the incidence of other problems developing.
While toe crests and hammer toe splints approach the problem from the point of view of positioning the toe correctly, other shoe aids focus on the elimination of friction between the interior shoe surface and the claw toes. These products generally consist of some form of insert filled with gel, which provides cushioning when the claw toe does happen to rub against the inside of the shoe. Two common approaches that use gel are toe shields and toe caps, both of which provide a softer environment inside the shoe. Claw toe sufferers will greatly appreciate the comfort that these shoe inserts can afford them.
If the use of orthopaedic inserts such as those described above does not provide sufficient relief, or if their use appears to help improve the underlying condition, a physician or other medical professional should be consulted.
Treatment Options for Claw Toe: Medical Options
One thing a podiatrist can do for claw toes that have not responded to the orthotic treatments described above is determine if custom made footwear inserts may be of use. Some podiatrists can make these for themselves; others will recommend a specialist who can take care of the matter. If your claw toe issues are caused by underlying factors such as flat footedness, it becomes somewhat likely that standard over the counter orthotics will not suit your needs and you could benefit from custom orthotics instead.
Claw toes that are detected early enough can sometimes be straightened without resorting to the more invasive method of surgery. If detection or diagnosis is delayed past a certain point, however, surgery becomes a primary means of treatment. In these cases, the soft tissues have become to the point that they cannot be stretched out again by manual or orthotic means.
Two primary types of claw toe surgery have been developed as viable treatment options for severe forms of the condition:
- athroplasty, and
Medical Treatment Options for Claw Toe: Arthroplasty
Arthroplasty is considered the more minor form of surgery and is used instead of arthrodesis whenever possible. In the surgical procedure known as arthroplasty, a single incision is made into the toe. An area of flesh inside known as the head of the proximal phalax will be trimmed down to the point at which it becomes possible for the toe to lie in a straightened position.
Arthroplasty may be successful after a single operation, but it is also common for more than one procedure to be performed in order for the degree of straightening to reach the desired level. In most cases where arthroplasty is undertaken, it is successful, although this may require repeated surgeries. In some cases, however, the procedure does not succeed in producing a sufficient degree of straightening. In these cases, the more intensive procedure of arthrodesis may be called upon.
Medical Treatment Options for Claw Toe: Arthrodesis
Utilized only in the most severe cases of claw toe, the surgical procedure known as arthrodesis involves fusing the middle phalanges together with the nearest bone. Prior to achieving this fusion, the cartilage that may interfere is removed. Fusion is achieved by use of a surgical pin which hold the bones in place until they have grown together. The pin is in most cases designed to be removed after fusion has been achieved, although sometimes it is left in place permanently. Removal of the pin, of course, will necessitate an additional surgery.
By fusing the phalanges with the nearest ("proximal" ) bone, the toes are forced to rest in a flat, straightened position. However, the surgery known as arthrodesis is a serious procedure. Patients who have had the surgery must stay completely off their feet for a few weeks afterwards, which can be highly inconvenient both in terms of lifestyle and when it comes to being able to hold onto their job.
Additionally, since the procedure is invasive surgery, complications can develop (this is also true of the less severe procedure of arthroplasty.) The most common complication is infection, which is generally treated with antibiotics. Numbness of the toes can be another side effect of arthrodesis.
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