Foot & Ankle
Toe clawing refers to deformities of the lateral toes, either in the horizontal and/or vertical planes. These toe claw deformities can lead to abnormal weight-bearing on the ground or in footwear, creating painful areas of hyper-pressure (“corns” or “calluses”). We will not detail here the deformities of the hallux (1st toe or “big toe”) but only those of the adjacent toes (from the 2nd to the 5th toes).
ANATOMY :
Toe or “toe fingers” constitute the termination of the forefoot. They serve a function in walking, as well as in balance and posture. The lateral toes are composed of a bony skeleton of 3 phalanges (proximal, middle, and distal phalanx) extending from the bony skeleton of the metatarsals.
There are thus 3 articulations:
- The metatarsophalangeal joint (MTP) between the metatarsal and the proximal phalanx;
- The proximal interphalangeal joint (PIP) between the proximal and middle phalanges;
- The distal interphalangeal joint (DIP) between the middle and distal phalanges.
These articulations are held together by a fibrous system allowing the mobilization of the two bony pieces relative to each other (“the joint capsule”), reinforced laterally by ligaments.
At its lower (plantar) part, the joint is reinforced by a thicker structure allowing it to resist pressure, the “plantar plate”.
The movement of these articulations is ensured by extensor and flexor tendons, respectively serving to extend and flex the toes. These tendons insert on the phalanges, the flexors on the underside, and the extensors on the upper side.
The distal phalanx carries the nail on its upper (dorsal) part and the pulp on its lower surface (plantar part). The toes possess numerous and important nerve endings, originating from 2 digital nerves (1 on each side of the toe), dividing into multiple microscopic nerve fibers ensuring sensitivity. This rich innervation explains the significant pain present in the pathology of these toes.
THE PATHOLOGY :
In the normal state, the toes are aligned next to each other, with contact on the ground at the pulp level. Their mobility is more limited than that of the hands but still allows for some lifting or flexion movements on the ground.
Toe claws encompass any deformity of the toes in the horizontal and/or vertical plane. These deformities result from disorders of bone orientation, tendon retractions, or joint abnormalities. These deformities can be isolated (affecting only one or two toes), be the consequence of a general condition (especially neurological pathology), or the result of deformity of the big toe. These deformities are quite varied as they can affect the three phalanges, the three joints (metatarsophalangeal, proximal interphalangeal, or distal interphalangeal), and the two tendon systems (flexors and extensors).
Among all possible deformities, we thus speak of:
- “Clinodactyly” for deformations in the horizontal plane (toes are deviated inward or outward);
- “Hammer toe” for a flexion deformity affecting the distal interphalangeal joint;
- “Total claw” for a flexion deformity involving both the proximal and distal interphalangeal joints.
These claw deformities can be reducible (“flexible claws”) or irreducible (“fixed claws”).
THE CLINIC :
These deformities will cause excessive pressure between the toes, between the toe and the ground, or between the toe and the shoe. Unlike normal pressure exerted between the ground and the toe pad (fleshy and cushioning area), the hyperpressure of a claw sits on a thin and exposed area, making it particularly painful.
This hyperpressure clinically manifests as localized pain and hyperkeratosis (callus or corn).
These calluses generally occur on the dorsal part of the joints but can also occur at the end of the toe on the pad and the nail (in the case of distal clawing), or on the lateral sides of the toes (in interdigital conflicts), forming a “corn.”
These calluses can progress to skin ulcerations that may lead to bone infection (osteitis), joint infection (arthritis), or infection of tendon tissues and fatty tissues (phlegmon).
DIAGNOSIS :
The consultation with a specialist is motivated by toe pain, corns, skin ulcers, and difficulty with footwear. The diagnosis is primarily clinical, based on the deformity of one or more toes with the possible presence of corns.
Radiographic evaluation is generally performed to assess the bone segments and joints. Ultrasound may be useful for studying peri-articular tissues (plantar plates) or tendon structures. CT scans and MRI can assess bone and tissue structures.
NON-SURGICAL TREATMENTS
SURGICAL TREATMENTS
ANESTHESIA
NON-SURGICAL TREATMENTS
Footwear modification is a first possibility: wearing wide and flexible shoes, or even specialized footwear, reduces contact and pressure on painful areas. Engaging in rehabilitation sessions and stretching exercises, which combat deformation, is also an option. The use of foot orthotics (podiatrist insoles) can reduce pain by unloading painful areas and rebalancing ground pressure. Custom-made and removable toe orthoses (elastic toe splints) can alleviate pain by maintaining the toes in a favorable position.
SURGICAL TREATMENTS
Surgical intervention may be recommended when deformities are too severe or conservative treatment proves ineffective.
All components of the deformity can be addressed:
- Bony deformity may be corrected through bone shortening or axis correction (osteotomy), which will then consolidate in a more favorable position.
- Articular deformity can be corrected by releasing the joint (arthrolysis), immobilizing it in a proper position (arthrodesis), or eliminating it through simple resection (arthroplasty).
- Tendinous deformity can be corrected through tendon release (tenotomy) or lengthening of the retracted tendon.
Modifications of tendon trajectory or insertion may also be performed to correct clawing.
ANESTHESIA
A preoperative consultation with an anesthesiologist is mandatory. During this consultation, the anesthesiologist will explain the anesthesia options tailored to the surgery and your health issues. Anesthesia may include local (numbing of the affected toe and metatarsal), regional (numbing a larger area from the leg to the toes), spinal (numbing the pelvic area and limbs by injecting between two vertebrae), or general anesthesia.
During this consultation, your current medication regimen will also be reviewed.
HOSPITALIZATION :
The procedure is performed on an outpatient basis in the vast majority of cases.
The duration of the procedure varies widely depending on the extent of the deformity and the number of toes to be operated on. An average duration of one hour is typical.
During the surgical procedure, you will be positioned supine on the operating table. This positioning allows your surgeon to access the dorsal part of the forefoot, between the toes, or even the plantar part. The incisions vary in size but typically do not exceed 2-3 cm.
Additionally, do not be surprised if you are asked to confirm your identity and the side to be operated on multiple times upon arrival and during the setup in the operating room. This is a mandatory procedure for all patients to ensure safety and accuracy.
The goal of toe claw surgery is to address all components of the deformity, whether they are related to tendons, bones, or joints. Thus, your surgeon may perform various procedures based on your specific deformity:
Bone and Joint Procedures:
- Osteotomy: This involves cutting a bone segment to realign it and correct the deformity. It can be performed on any of the three bone phalanges or the metatarsal.
- Resection Arthroplasty: This entails the removal of deformed joint surfaces through a dorsal incision, allowing proper alignment of the bone segments. A fibrous scar forms in the space left by the removed joint surface, contributing to maintaining the correction.
- Arthrodesis: This involves stabilizing and fusing the joint in the correct position using temporary pins, screws, or implants.
- Arthrolysis: This procedure releases adhesions around a deformed joint to allow it to resume a more favorable position.
Tendon Procedures:
- Tenotomy: Cutting the retracted tendons responsible for or perpetuating the deformity.
- Tendon Lengthening: Lengthening certain tendons to reduce the traction they exert on the bone segments where they insert.
- Tendon Transfers: Redirecting a retracted tendon to a location where it will counteract the deformity.
These surgical techniques may require the placement of operative materials to stabilize the correction. These materials can include screws, pins, plates, metallic or non-metallic implants. Some materials, such as certain pins, may be visible initially and removed after a few weeks. Others are intended to remain implanted.
During the procedure, unexpected or unusual situations may arise, necessitating additional or alternative actions. Your surgeon will explain the surgical approach and procedures performed once you are awake and the surgery is complete.
POSTOPERATIVE PAIN varies depending on the extent of the intervention: a procedure involving bone and soft tissues on all five toes will be more intense than a solely tendon procedure on one toe… although strong painkillers may be used immediately after, returning home with simple painkillers is standard. Anticoagulant injections may also be prescribed depending on your health status and the extent of the intervention.
WEIGHT-BEARING is generally allowed with a post-operative shoe or roomy footwear. For more fragile patients, crutches may be used to prevent falls due to clumsiness. In general, you will be able to manage daily activities at home independently, but driving or engaging in sports may not be possible initially…
DRESSINGS are carefully done during the procedure according to your surgeon’s routine, and usually should not be altered. Particularly in percutaneous surgery, dressings are more specific and performed by your surgeon and their team. However, if home care is necessary, it’s important to maintain hygiene around the incision while the stitches are present and it’s not completely sealed. Hand hygiene is crucial, and the incision should never be touched without washing hands. Always ensure you have a hand washing point or a bottle of hand sanitizer for the nurse who will perform your care.
PREVENTION OF THROMBOPHLEBITIS Prescribing anticoagulant injections is rare in this type of surgery but may be considered based on assessment of your health by the surgeon and anesthesiologist.
POSTOPERATIVE EDEMA (swelling of the foot and toes) is common in ankle and foot surgery and is not a complication. Managing the swelling is essential not only for pain relief but also to improve wound healing quality: thus, a period of rest, elevation, and wearing compression stockings or varicose vein stockings may be helpful. This edema can last for a long time (several weeks to several months) and usually does not cause issues; it may require temporary shoe adjustments.
POSTOPERATIVE FOLLOW-UP is crucial. It spans over several months, allowing for monitoring of wound healing, multiple dressing changes, and guiding toe consolidation into the desired position.
These appointments will also be an opportunity to review pain management and start rehabilitation (either by yourself or with a physiotherapist). You will also be guided on footwear adaptation.
AFTER THE INTERVENTION ?
In the absence of intervention, these toe clawing deformities continue to worsen. Footwear becomes increasingly difficult or even impossible, affecting your ability to walk… The goal of surgery is to achieve toes that lie flat with contact on the ground.
However, the postoperative result naturally depends on the initial deformity: for mildly deformed claws, complete reduction of the deformity will be the goal, whereas for the most severe cases, the aim is to regain wide and comfortable footwear.
Adapted from the information sheet of the French Society of Foot Surgery (Société Française de Chirurgie du Pied – SFCP).
