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Fundamentals of clawtoes/hammertoes

Clawtoes are bent at the middle and end joints, and a dorsiflexion (a muscle that causes upward flexion) deformity at the metatarsal phalangeal joint. Hammertoes are bent at the middle joint only, with a dorsiflexion deformity at the metatarsal phelanged joint. The condition can cause pressure and pain and usually occurs in the four smaller toes.  The joints of the toes buckle abnormally, and have a curved, claw-like, or hammer-like, appearance. Additionally, clawtoes are often associated with a high arched (cavus) foot type, or occasionally some other neurological condition.

Corns or calluses may result from the pressure and rubbing on the bottom of the shoe or on the top of the toes.  Rarely, infections may occur.  Ulcers may develop in diabetic patients because of decreased foot sensitivity.

Toe deformities can be congenital.  Additionally, those with high arches, or those who tend to rotate their feet inward while walking, are susceptible to toe deformities.

What causes the pain?

An imbalance of foot muscles typically causes clawtoes and hammertoes.  Foot muscles become imbalanced due to the following factors:

  • Ill-fitting shoes (by far #1)
  • Diabetes
  • Rheumatoid or osteoarthritis
  • Alcoholism
  • Charcot-Marie-Tooth Disease
  • Spinal cord tumors
  • Polio
  • Stroke

How is it treated?

Non-surgical treatment for clawtoes and hammertoes includes:

  • Wearing shoes that have roomy toe boxes, low heels, and good arch supports.
  • Wearing shoes that offer increased width and depth, with soft soles and minimal seams in the toebox.
  • Wearing pads, arch supports, or other shoe inserts to cushion the toe.
  • Strengthening and stretching toe muscles through exercises.

Surgical treatment of clawtoes and hammertoes includes:

  • Tendon lengthening and rerouting.
  • Shortening the bones of the phalanx.
  • Temporarily inserting a steel pin to hold the correct position of the toe until healing occurs.

What are the risks of treatment?

Risks include nerve injury, infection, and stiffness.  Recurrence of the toe deformity can occur, especially if you return to wearing ill-fitting shoes.

How do I prepare for surgery?

Always ask your surgeon for complete pre-operative preparation instructions.  Typically, these may include:

  • Complete any pre-operative tests or lab work prescribed by your doctor.
  • Arrange to have someone drive you home from the hospital.
  • Refrain from taking aspirin and non-steroidal anti-inflammatory medications (NSAIDs) one week prior to surgery.
  • Call the appropriate surgery center to verify your appointment time. 
  • Refrain from eating or drinking anything after midnight the night before surgery.  

Are there exercises I can start now prior to surgery?

In preparation of any foot/ankle surgery, upper body strengthening is encouraged in order to prepare for crutch/walker use after surgery.

What do I need to do the day of surgery?

  • If you currently take any medications, take them the day of your surgery with just a sip of water.
  • Refrain from taking diabetic pills or insulin on the morning of surgery.
  • Do not wear any jewelry, body piercings, makeup, nail polish, hairpins or contacts. 
  • Leave valuables and money at home.
  • Wear loose-fitting, comfortable clothing.

What happens during surgery?

Your foot will be initialized in the preoperative area by someone from the surgical team.  In the operating room, you will be met by a nursing team and the anesthesia team. You have several anesthetic options:

  • General: Completely asleep and breathing through a tube
  • Epidural/Spinal: Numb from the waist down, or
  • Local: Numbing medicine just above the surgical site

Epidural/Spinal and Local are usually combined with sedative medication so you can rest comfortably during the procedure.  Once you are anesthetized, the surgery is initiated.

What happens after surgery?

It is not unusual to experience numbness, tingling, and burning sensations in your foot or ankle.  You should elevate your foot above your heart for 48 hours after the procedure, in order to relieve pain and these sensations.  If this does not resolve the problem, your cast or surgical dressing may be too tight, and you may need to call your doctor.  Avoid prolonged sitting or standing, and refrain from putting weight on the operative site unless given permission by your doctor.   

Your doctor will give you pain medication, which may cause nausea or constipation.  Eat lightly on the day of surgery.

If you are wearing a cast, do not put anything in the cast and keep the cast clean and dry.  If you are itching beneath the cast, take Benadryl and blow cool air down the cast with a hair dryer. 

Follow-up X-rays may be required to ensure the foot is healing properly.  These are usually done 3-6 weeks after surgery. Additionally, patients are typically required to wear a post-operative shoe. If a pin is in the foot, then it is important not to bear weight on the forefoot, or the pin can bend or break.

After the first 48 hours of foot elevation, you can usually gradually return to most activities.  However, the use of crutches or a walker will be required. At some point, your physician will allow you to wean off the crutches/walker to more “normal” activities.  Typically, the dressing placed at the time of surgery is left intact until your first postoperative visit.  The surgical dressing cannot get wet.  Therefore, baths are encouraged.  If one chooses to shower, then an “over-the-cast” bag is necessary.

Ask your surgeon for complete post-operative instructions.

How long is the recovery period after surgery?

Full recovery typically requires between 6 and 12 weeks. Swelling is the “enemy” after surgery and precautions must be taken to minimize it.  A slow, gradual return to activities is encouraged.

What is the rehab after surgery?

Foot and ankle surgery rehabilitation can be done at home, or, may require formal physical therapy.

How frequently should I schedule follow up appointments with my doctor following surgery?

Follow-up visits are scheduled by your surgeon.

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