Claw toe is a deformity of the toes where they bend into a claw-like position. This condition typically affects the second to fifth toes and is characterized by abnormal bending at the middle (proximal interphalangeal) and end (distal interphalangeal) joints, while the base joint (metatarsophalangeal) may extend upward. As a result, the toe appears curled downward, resembling a claw. Claw toe can be flexible in its early stages but may become rigid over time if left untreated.

This deformity is often associated with an imbalance in the muscles, tendons, or ligaments that normally hold the toe straight. It may develop due to underlying conditions such as diabetes, rheumatoid arthritis, or neurological disorders, or it can result from wearing ill-fitting shoes that crowd the toes. Claw toe can cause pain, difficulty walking, and the formation of corns or calluses due to abnormal pressure on the toes.

Claw toe and hammer toe deformities are relatively common, with prevalence estimates ranging from 2% to 20%, and their occurrence tends to rise with age. These conditions are most frequently observed in individuals in their 70s and 80s. Women are significantly more affected than men, with a ratio of about four to five times higher. However, there is limited information in the medical literature about the occurrence of these deformities in populations that do not wear shoes.

Although many individuals with claw toe do not have a specific underlying disorder, the condition can be linked to certain neuromuscular diseases, including multiple sclerosis, Charcot-Marie-Tooth disease, Friedreich ataxia, cerebral palsy, mild dysplasia, stroke, and impingement of the lumbar nerve roots. Additionally, systemic illnesses such as diabetes and inflammatory joint diseases like rheumatoid arthritis and psoriasis may also be associated with the development of claw toe.

Claw toe develops due to an imbalance between the intrinsic and extrinsic muscles of the foot. Under normal circumstances, the intrinsic foot muscles such as the lumbricals and interossei work in coordination with the extrinsic muscles like the flexor digitorum longus and extensor digitorum longus to maintain proper toe alignment and movement. In claw toe deformity, this balance is disrupted.

The deformity is primarily characterized by hyperextension at the metatarsophalangeal (MTP) joint and flexion at both the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. When the intrinsic muscles weaken or lose function due to aging, neuromuscular disorders, or systemic diseases the stronger extrinsic muscles overpower them. This leads to unopposed extension at the MTP joint and excessive flexion at the PIP and DIP joints.

Over time, this abnormal toe posture causes adaptive shortening of tendons and joint capsules, resulting in fixed, rigid deformities if not corrected. In chronic cases, joint subluxation or dislocation, soft tissue contractures, and development of corns or calluses due to abnormal pressure on the toe tips and dorsal surfaces may occur. Claw toe can also affect gait and weight distribution, leading to pain and functional impairment.

Claw toe is caused by an imbalance between the foot’s intrinsic and extrinsic muscles, often due to prolonged use of ill-fitting shoes, muscle weakness, or neurological conditions. It commonly occurs in older adults, especially women, and may be associated with systemic diseases like diabetes, rheumatoid arthritis, or nerve disorders such as Charcot-Marie-Tooth disease. Trauma, hereditary factors, and aging also contribute to its development. In many cases, no specific cause is identified.

The prognosis of claw toe depends on several key factors, including the underlying cause, the flexibility of the deformity, the duration of symptoms, and the effectiveness of early intervention. Flexible deformities have a better prognosis, as they are more likely to respond to conservative treatments such as footwear modification, orthotics, and exercises. In contrast, rigid deformities or those caused by progressive neuromuscular diseases tend to have a poorer outcome and may require surgical correction.

Age group

Claw toe most commonly affects older adults, particularly those in their seventh and eighth decades of life (ages 60–80 years). The risk increases with age due to muscle weakening, joint stiffness, and prolonged exposure to risk factors such as poorly fitting footwear. While it can occur at any age, especially in individuals with underlying neuromuscular or systemic conditions, it is significantly more prevalent among the elderly. Women are also affected more frequently than men.

On physical examination, claw toe is identified by the characteristic hyperextension at the metatarsophalangeal (MTP) joint and flexion at the proximal (PIP) and distal interphalangeal (DIP) joints of the affected toes, usually the second to fifth. The deformity may be flexible in early stages, meaning it can be manually straightened, or rigid in advanced stages, where the joint positions are fixed.

Additional findings may include calluses or corns over the dorsal PIP joints or the tips of the toes due to pressure from footwear. The examiner should assess for muscle strength, sensory deficits, and gait abnormalities, especially if a neurological cause is suspected. Evaluation of footwear is also important, as ill-fitting shoes often contribute to symptom progression. A full neurovascular exam should be conducted to rule out peripheral neuropathy, particularly in patients with diabetes or suspected systemic illness.

Rheumatoid arthritis

Charcot-Marie-Tooth disease

Cerebral palsy

Spinal cord disorders

Claw toe typically presents as a chronic, gradually progressive condition rather than an acute one. In most cases, the deformity develops slowly over time due to long-standing muscle imbalance, systemic disease, or prolonged mechanical stress. Early in its course, the toe may remain flexible and painless, but as the deformity progresses, it can become rigid and symptomatic, causing discomfort, calluses, and difficulty with footwear.

Conservative Treatment (preferred for flexible or early-stage deformities):

Footwear modification: Using shoes with a wide toe box and low heels to reduce pressure on the toes.

Toe padding or orthotic devices: To relieve pressure and prevent corns or calluses.

Physical therapy: Stretching and strengthening exercises for intrinsic foot muscles to improve alignment and function.

Splinting or taping: Helps maintain proper toe position in flexible deformities.

Treatment of underlying conditions: Managing systemic or neurological diseases (e.g., diabetes, rheumatoid arthritis) to prevent progression.

Surgical Treatment (considered when conservative methods fail or the deformity becomes rigid):

Soft tissue procedures: Such as tendon lengthening, capsulotomy, or flexor-to-extensor tendon transfer in flexible deformities.

Joint procedures: Arthroplasty or arthrodesis for rigid or painful deformities to correct alignment and relieve symptoms.

MTP joint release: In cases with significant metatarsophalangeal joint hyperextension or subluxation.

Orthopaedic Surgery

Proper Footwear:

Use shoes with a wide and deep toe box to prevent toe crowding and reduce pressure on deformities.

Avoid high heels and pointed-toe shoes, which worsen toe positioning.

Opt for soft, cushioned insoles to reduce pressure under the toes.

Home Safety Adjustments:

Remove tripping hazards like loose rugs or clutter to prevent falls, especially in elderly patients with balance issues or neuropathy.

Ensure adequate lighting and install grab bars or handrails in bathrooms or stairways.

Use of Assistive Devices:

Consider toe spacers, pads, or orthotic inserts to reduce friction and improve toe alignment.

Use non-slip socks or slippers indoors to provide better grip and prevent slips.

Workplace Accommodations:

Allow for frequent sitting breaks if prolonged standing worsens symptoms.

Use a footrest or ergonomic mat for support if standing is necessary.

Orthopaedic Surgery

Surgical intervention for claw toe is considered when conservative measures fail, especially in cases of rigid deformities, significant pain, or functional impairment. The choice of procedure depends on the flexibility of the toe, severity of the deformity, and the presence of associated conditions like joint subluxation or soft tissue contracture.

For flexible deformities, soft tissue procedures are often sufficient. These may include flexor to extensor tendon transfer, where the flexor tendon is rerouted to help correct toe posture and rebalance muscle forces. Capsulotomy or tenotomy may also be performed to release tight joint capsules or tendons, allowing better toe alignment.

In rigid or advanced cases, bony procedures are usually necessary. Arthroplasty (removal of part of the joint, often the head of the proximal phalanx) may be performed to relieve pressure and improve alignment. In more severe or fixed deformities, arthrodesis (fusion of the joint) is done to stabilize the toe in a corrected position and eliminate movement at a painful or unstable joint.

Additional procedures may include metatarsophalangeal (MTP) joint release or metatarsal osteotomy if there is significant MTP joint hyperextension or subluxation. Postoperatively, patients may require splinting, physical therapy, and modifications in footwear to support healing and prevent recurrence.

Orthopaedic Surgery

The management of claw toe is typically carried out in distinct phases, depending on the severity, flexibility of the deformity, and the underlying cause.

In the preventive phase, the focus is on reducing the risk of developing claw toe, especially in individuals at risk due to age, systemic diseases like diabetes, or prolonged use of poorly fitting shoes. Preventive strategies include wearing properly fitted footwear with a wide toe box, performing regular toe and foot exercises to maintain muscle balance, and managing systemic conditions that may contribute to muscle weakness or nerve damage. Regular foot inspections are especially important for individuals with sensory deficits or neuropathy.

The conservative phase is appropriate for patients with flexible deformities. The goal here is to relieve symptoms and maintain or restore normal toe alignment. Treatment includes modifying footwear to reduce pressure on the toes, using toe pads or orthotic devices, and performing physical therapy to strengthen the intrinsic foot muscles and improve flexibility. Conservative care also involves managing associated problems such as calluses or corns and avoiding activities that aggravate the condition.

When the deformity becomes rigid or painful, the corrective phase is initiated. This phase often involves surgical correction, particularly if conservative methods have failed. Surgical options may include tendon lengthening, joint release, arthroplasty, or arthrodesis, depending on the severity and structure involved. Postoperative care includes rehabilitation with physiotherapy and gait training to restore function and mobility.

The final maintenance phase focuses on preventing recurrence and preserving foot function following treatment. Long-term strategies involve the continued use of appropriate footwear and orthotic support, adherence to exercise regimens, and regular follow-up with healthcare providers. Ongoing management of any systemic or neurological conditions remains crucial to prevent further deterioration and complications.

Each of these phases plays a vital role in ensuring that the condition is managed effectively, improving patient comfort and maintaining mobility.