Claw toes have PIP flexion and MTP hyperextension
(irreducible). You may also find DIP flexion. The claw toe deformity is usually
associated with an underlying neurologic condition such as diabetic peripheral
neuropathy and Charcot-Marie-tooth disease. Claw toes deformity of the lesser
toes can follow severe closed calcaneal fracture as a result of contracture of
the intrinsic flexor muscles of the foot. Excision of the lateral and medial
sesamoids may lead to claw toes. In claw toes, there is a muscle imbalance
where the extrinsic muscle overpowers the weaker intrinsic muscle and can cause
claw toes. The claw toe and hammer toe deformities are associated with dorsal
subluxation of the interossei, which can no longer serve to flex the
metatarsophalangeal joint. Once the MTP joint extends, the tendon imbalance
becomes a vicious cycle. It is important to recognize if these deformities are
rigid (fixed) or flexible. Claw toes is different from mallet toe, hammer toe,
curly toe, and crossover second toe. The isolated hammer toe and the mallet toe
usually result from an acute injury or from chronic pressure from shoes. Hammer
toe rarely occurs by itself, and you may have a disorder of the plantar plate.
The hammer toe and the claw toe differ by the position of the DIP joint. In the
hammer toes, you will find flexion of the PIP and extension of the MTP joint,
but it is reducible. Hammer toe can occur by itself, and there might be an
associated dorsal PIP callus. You may also find second toe metatarsalgia. The
condition of hammer toe can be flexible or rigid. In mallet toe, there is a DIP
flexion deformity. You can find nail pain and end bearing callus. In mallet
toe, the extensor digitorum longus will lose its tenodesis effect on the
proximal interphalangeal and distal interphalangeal joints. Curly toe is
associated with contracture of the flexor tendons and usually occurs in
children. Curly toe is usually bilateral and usually affects the third or the
fourth toe. The affected toe is usually flexed and curved medially, so that toe
lies underneath the neighboring medial toe. The curly toe is usually
asymptomatic, and it may improve by itself. The nail of the curly toe may cut
the plantar surface of the overlying toe. The condition of curly toes is
usually caused by tight flexors of the toe. The condition usually does not need
treatment, and you may need to stretch the toe. If stretching of the toe fails,
then you may need to do release of the flexor tendon (flexor tenotomy).
Crossover second toe usually occurs due to attenuation or rupture of the
plantar plate and the lateral collateral ligament. They are associated with a
varying degree of instability. With crossover second toe, there will be
progressive migration of the digit towards the big toe (usually the second one)
with dislocation or subluxation of the MTP joint.
