summary Claw toe is a lesser toe deformity characterized by MTP hyperextension and resulting PIP and DIP flexion. Diagnosis is made clinically with presence of MTP hyperextension, PIP flexion and DIP flexion of a lesser toe. Treatment is a trial of nonoperative management with shoe modification and taping. Surgical management is indicated for progressive deformity, fixed contractures, and dorsal toe ulcerations. Epidemiology Anatomic location typically involves multiple toes often bilateral Etiology Pathophysiology MTP hyperextension is the primary pathology chronic MTP hyperextension leads to unopposed flexion of the DIP and PIP by FDL analogous to intrinsic minus deformity in the hand the MTP plantar plate becomes insufficient over time base of proximal phalanx translates dorsally interossei and lumbricals move dorsally shifts flexion moment arm to the wrong side of the center of rotation Cause synovitis is the most common cause trauma delayed or missed compartment syndrome involving the deep posterior compartment of the leg or foot Associated conditions cavus deformity neuromuscular disease affecting intrinsic and extrinsic muscle balance clawing of all 4 lesser toes implicates a neurologic abnormality inflammatory arthropathies lead to soft tissue structure attenuation and MTP joint instability Classification Claw toe vs. Hammer toe vs. Mallet toe Claw Toe Hammer Toe Mallet toe DIP Flexion Extension Flexion PIP Flexion Flexion Normal MTP Hyperextension Slight extension Normal Presentation Symptoms pain at the level of the unstable MTP joint metatarsalgia Physical exam inspection & palpation claw-type deformity of the toe is present depressed metatarsal head with callus formation and tenderness flexed IP joints with callosities and tenderness Treatment Nonoperative taping and shoe modification indications first line of treatment techniques provide adequate plantar padding using metatarsal and/or crest pads or orthotics to offload plantarly-subluxed metatarsal heads wear a shoe with a high toe box use a sling to hold the proximal phalanx parallel to the ground Operative EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer (Girdlestone) indications painful, flexible deformities without contractures ulcerations caused by shoe wear Girdlestone (above), MTP capsulectomy, and proximal phalanx head and neck resection indications fixed contracture Girdlestone and distal MT shortening osteotomy (Weil lesser MT osteotomy) indications claw toe deformity of all four lesser toes technique oblique shortening osteotomy translates metatarsal head proximal and plantar Isolated FDL tenotomy indications flexible deformity in a diabetic patient with tip-of-toe ulceration without evidence of infection Complications Floating toe most common complication of a Weil osteotomy caused by intrinsics migrating dorsal to the joint and acting as MTP extensors Recurrence caused by persistent plantar plate dysfunction