Claw Toe

Lower Limb

Overview

Claw toe is a progressive flexion deformity of the interphalangeal joints with dorsal subluxation of the metatarsophalangeal joint, most commonly affecting the second through fifth toes. The condition results from intrinsic muscle weakness, extrinsic muscle imbalance, or structural abnormalities in the foot. It can cause significant functional impairment, pain, and difficulty with footwear.

Pathophysiology

Claw toe develops when there is an imbalance between intrinsic foot muscles (interossei and lumbricals) and extrinsic muscles (flexor and extensor digitorum). Intrinsic muscle weakness allows unopposed action of the extrinsic flexors, causing flexion of the distal interphalangeal joint and plantarflexion of the proximal interphalangeal joint. The metatarsophalangeal joint hyperextends secondarily, creating dorsal prominence. Common causes include: neurological conditions (stroke, Charcot-Marie-Tooth disease, spinal cord injury), inflammatory arthropathies (rheumatoid arthritis), chronic compartment syndrome, prolonged immobilization, or idiopathic intrinsic muscle atrophy. Repetitive pressure from footwear exacerbates the deformity.

Patient Education

Claw toe often progresses gradually, but early intervention with footwear modification, intrinsic muscle strengthening, and stretching can prevent fixed deformity and reduce pain; surgical intervention may be necessary if conservative management fails.

Typical Presentation

Site

Second through fifth toes, most commonly the second toe; dorsal aspects of proximal interphalangeal joints and plantar aspects of metatarsal heads

Quality

Aching, sharp pain at pressure points; burning sensation; numbness in severe cases

Intensity

Mild to moderate pain that worsens with prolonged standing or walking; pain 3-7/10 depending on severity

Aggravating

Tight or constrictive footwear; prolonged standing or walking; weight-bearing activities; pressure on dorsal prominences

Relieving

Rest and elevation; removal of constrictive footwear; padding or orthotics; anti-inflammatory medications; ice application

Associated

Calluses and corns on dorsal proximal interphalangeal joints and plantar metatarsal heads; hammertoe appearance; metatarsalgia; difficulty walking; functional foot pain; visible dorsal toe prominence; reduced toe mobility; associated forefoot pain

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Tinel's Sign (Tarsal Tunnel Syndrome Screening)

Procedure

Tap over the tibial nerve behind and below the medial malleolus.

Positive Finding

Tingling spreading into the sole or toes.

Interpretation

Screens for tibial nerve entrapment, which can weaken the foot intrinsic muscles. It is a screening step only; a positive result needs a full neurological assessment. The figure stored here belongs to tarsal tunnel syndrome, not to this condition, so no figure is shown.

Sources

No accuracy study

Claw Toe Deformity Assessment (Visual/Positional)

Procedure

Observe the toes in sitting and standing. Note the MTP, PIP and DIP positions, how many toes are affected, and whether one or both feet are involved.

Positive Finding

Extension at the MTP joint with flexion at the PIP and DIP joints.

Interpretation

Confirms a claw toe. Several toes on both feet raise the question of a neurological or systemic cause (peripheral neuropathy, diabetes, inflammatory arthritis); a new claw toe on one side suggests a nerve or muscle problem and needs neurological screening.

Sources

No accuracy study

Neurological Screen (Lower Limb)

Procedure

Test sensation, reflexes (knee and ankle) and power in the lower limb, including toe extension (L5) and toe flexion (S1), and check sensation on the sole.

Positive Finding

Sensory loss, reduced reflexes or weakness.

Interpretation

Looks for a neurological cause of claw toes, such as peripheral neuropathy or nerve root compression. The prone knee bend tests the femoral nerve (L2–L4), not the nerves that supply the foot muscles.

Sources

No accuracy study

Intrinsic Muscle Strength Testing (Lumbrical/Interossei Function)

Procedure

Ask the patient to straighten the toes and press them flat into the floor, or to spread the toes apart, or to grip a towel with the toes. Compare with the other foot.

Positive Finding

Unable to hold the toes flat, spread them, or grip.

Interpretation

Weak foot intrinsic muscles allow the long toe extensors and flexors to pull the toes into a claw. This guides toe and foot strengthening.

Sources

No accuracy study

Passive Corrective Test (Flexibility Assessment)

Procedure

Try to straighten each joint of the toe gently, first with the ankle relaxed and then with it dorsiflexed.

Positive Finding

The toes cannot be straightened (fixed), or claw more when the ankle is dorsiflexed.

Interpretation

Flexible deformities may respond to footwear, padding and exercise; fixed ones may need surgery. Clawing that increases with ankle dorsiflexion suggests tight long toe flexors.

Sources

Not a diagnostic test

Silfverskiöld Test

Procedure

Patient supine. Hold the heel in neutral and dorsiflex the ankle with the knee straight, then bent to 90°. Compare with the other side.

Positive Finding

Dorsiflexion limited with the knee straight and better with it bent.

Interpretation

Calf tightness increases forefoot loading and may contribute to toe deformities. A treatment target, not a diagnostic test.

Sources

⚠ Red Flags

  • •Signs of vascular compromise (colour changes, coolness, absent pulses)
  • •Evidence of diabetic foot ulceration or infection
  • •Severe neurological deficit with progressive weakness
  • •Acute trauma with severe deformity or fracture
  • •Signs of complex regional pain syndrome
  • •Unexplained systemic symptoms suggesting underlying systemic disease

⚡ Yellow Flags

  • •High fear-avoidance beliefs regarding foot pain and activity
  • •Catastrophising about surgical necessity
  • •Significant functional disability disproportionate to structural findings
  • •Occupational demands requiring prolonged standing or specific footwear
  • •Body image concerns related to visible toe deformity
  • •Resistance to conservative management due to unrealistic expectations
  • •Depression or anxiety related to chronic pain and functional limitations

Osteopathic Techniques

Claw toe (both toe joints bent, with the MTP joint extended) is managed like a hammertoe at first: insoles or orthotics, wide toe-box shoes, padding of painful calluses, and strapping or taping a flexible deformity. These ease pain but do not correct it; surgery is considered once the contracture is fixed and painful. No trials of osteopathic techniques were found.

Safety: Claw toes often affect several toes on both feet and are commonly linked to neuromuscular conditions and a cavus (high-arched) foot. When several toes or both feet are involved, screen for a neurological cause and refer if one is suspected.

Region

Intrinsic foot muscles, plantar fascia and flexor digitorum brevis

Technique

Soft tissue, foot and ankleNo trials found

Rationale

Soft tissue to the plantar fascia, foot muscles and the tissues around the toe joints and ankle ligaments.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the plantar fascia, the small muscles of the foot and the tissues around the heel and the ankle ligaments.

Evidence in Claw Toe

Searched 25 Oct 2026: no trials of foot soft tissue in claw toe.

Sources

Region

Metatarsophalangeal joints of affected toes, ankle and subtalar joints

Technique

Articulation, ankle and footNo trials found

Rationale

Gentle glides of the toe, midfoot and ankle joints to restore foot mobility.

How it's done, cautions & evidence

How it's done

Passive, rhythmic, low-velocity glides of the ankle (talocrural), subtalar, midfoot and toe joints, within or up to the end of the available range, often aimed at restoring ankle dorsiflexion.

Cautions

Before mobilising an acute ankle injury, check for fracture with the Ottawa ankle rules (tenderness over either malleolus), and palpate the base of the 5th metatarsal, the navicular and the midfoot for a Lisfranc injury.

Evidence in Claw Toe

Searched 25 Oct 2026: no trials of toe or foot mobilisation in claw toe.

Region

Gastrocnemius-soleus (calf)

Technique

Muscle energy, calf (gastrocnemius and soleus)No trials found

Rationale

Calf muscle energy technique to ease gastrocnemius-soleus tightness that limits ankle dorsiflexion.

How it's done, cautions & evidence

How it's done

The calf is taken to its barrier by dorsiflexing the ankle. The patient pushes the foot gently down, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Claw Toe

Searched 25 Oct 2026: no trials of calf muscle energy technique in claw toe.

Region

Anterior lower leg and long toe extensors

Technique

Soft tissue, calf and lower legNo trials found

Rationale

Calf and lower-leg soft tissue is usually given alongside a loading or stretching programme.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the calf (gastrocnemius and soleus), the Achilles tendon and the peroneal and tibial muscles of the lower leg. In trials it was given alongside exercise, such as eccentric calf loading.

Evidence in Claw Toe

Searched 25 Oct 2026: no trials of lower-leg soft tissue in claw toe.

Rehabilitation Exercises

Short Foot Exercise (Intrinsic Muscle Activation)

StrengtheningBeginner

Towel Scrunching with Toes

StrengtheningBeginner

Marble or Coin Picking with Toes

StrengtheningBeginner

Toe Extension and Flexion Active Range of Motion

Range of MotionBeginner

Plantar Fascia and Toe Flexor Stretch

StretchingBeginner

Calf Muscle Stretch (Gastrocnemius and Soleus)

StretchingBeginner

Toe Extension Resistance with Resistance Band

StrengtheningIntermediate

Gait Training with Toe Extension Focus

PosturalIntermediate

Single-Leg Balance with Intrinsic Foot Muscle Engagement

BalanceIntermediate

Seated Toe Flexor Stretching with Manual Assistance

StrengtheningIntermediate

Metatarsophalangeal Joint Mobilisation with Hand

Range of MotionAdvanced

Barefoot Standing and Walking on Varied Surfaces

BalanceAdvanced

Referral Criteria

  • •Fixed deformity unresponsive to conservative management after 12 weeks of consistent treatment and exercise
  • •Severe functional impairment affecting activities of daily living and quality of life
  • •Development of skin breakdown, ulceration, or signs of infection requiring podiatric or surgical assessment
  • •Underlying systemic disease (rheumatoid arthritis, diabetes, neurological condition) requiring specialist medical management
  • •Presence of neurovascular compromise suggesting vascular insufficiency
  • •Suspected associated fracture, significant joint damage, or osteoarthritis requiring imaging and specialist assessment
  • •Failed conservative management with consideration for surgical correction (podiatric surgery)
  • •Progressive neurological deficit suggesting spinal cord pathology or serious neurological disease