Figure 26

Figure 27

Claw toes and Hammertoes are fairly common conditions among people in cultures that wear shoes. In most cases, these problems can be traced to improperly fitting shoes.

Anatomy

The hammertoe deformity usually consists of hyperflexion deformity of the proximal interphalangeal joint (PIP). Clawing of the lesser toes is a combination of the hammertoe deformity, plus hyperextension of the metatarsal phalangeal (MTP) joint. This is usually the result of a shoe that is too short. (Figure 26: picture of PIP and MTP joint in a claw toe)

In many people, the second toe is actually longer than the great toe and if shoes are sized to fit the great toe, the second (and maybe even the third toe) will have to bend to fit into the shoe.

Shoes that are pointed make matters even worse. Combine pointed shoes with high heels and the foot is constantly being pushed downhill into a wall. The toes are swished like an accordion all the time! (Figure 27: x-ray of toe in shoe)

Symptoms

Eventually, toes that are squished day after day become fixed in that position and will not straighten out. When this occurs, pressure builds in three places:

• At the end of the toe
• Over the PIP joint
• Under the MTP joint

This causes painful calluses to develop due to pressure from the shoe.

Diagnosis

Diagnosis of these two conditions is obvious from the physical exam. In some cases, it is important to check to make sure no other nerve problems are to blame for the condition; special tests may be required.

Medical Treatment

Treatment depends on how far the process has progressed. Early in the process, simply switching to shoes that fit properly can stop the process and return the toes to a more normal condition. If the condition is more advanced and the toes will not completely straighten out on their own, a contracture may exist.

Pressure points and calluses caused by the contractures can be treated by switching to shoes that have more room in the toes or by placing pads over the calluses to relieve the pressure.

Surgery

If all else fails, surgery may be suggested to correct the alignment of the toe.

One of the most common procedures to correct the contracture of the PIP joint in both hammertoe and claw toe deformities is an arthroplasty of the PIP joint. In this procedure an incision is made over the PIP joint. The end of the proximal phalanx is then removed to shorten the toe and relax the contracture around the joint. The toe is then held in the straight position with pins or sutures until a false joint develops.

If clawing is a problem, then the MTP joint may also have to be released to relieve the contracture of this joint and allow the proximal phalanx to come into the correct position.

After surgery, you will usually be fitted with a postoperative shoe with a stiff, wooden sole that protects the toes by keeping the foot from bending. Pins are usually removed after 2 or 3 weeks.