Excerpted from "A Toe-Curling Experience," Stroke Connection Magazine, March/April 2004 (Science update August 2009)About six months after Katherine Ware had a stroke in 1996, she noticed that her small toes had begun to curl beneath her left foot. Wearing shoes became problematic and walking was painful. Her stroke physician referred her to a podiatrist, who identified her malady — a condition called “claw toe.”
Claw toe, and a similar condition called “hammertoe,” are caused by an imbalance of muscles in the feet and toes. Brain injury during a stroke leaves survivors prone to neuromuscular imbalances. With claw toe, muscles in the foot over-contract due to a neurological abnormality.
Claw toe and hammertoe are very similar conditions, differing in the muscles affected — flexor digitorum brevis and flexor digitorum longus, respectively. For this reason, the terms “claw toe” and “hammertoe” are often used interchangeably.
- Because toe muscles are typically not very strong, the contracting muscle overpowers the muscles in the toe.
- This tightens the tendons, causing the joints of the smaller toes to buckle or curl in an unnatural way.
- Claw toe most often strikes the stroke-side foot.
- Painful blisters may develop on the affected toes where their tips dig into the shoe.
- Added pressure from the imbalance may also cause calluses or corns to form on the ball of the foot.
- Claw toe also affects patients with joint diseases such as rheumatoid arthritis, cerebral palsy, nerve damage due to poor circulation, as with diabetes, and those confined to bed for a long time.
Flexible Claw Toe
“Flexible claw toe” describes the earlier stages in which, as the name suggests, the toes are still flexible at the joint. The American Academy of Orthopaedic Surgeons (AAOS), in conjunction with the American Orthopaedic Foot and Ankle Society, offers these suggestions for helping to correct the imbalance of flexible claw toe:
- Follow your doctor's instructions and use a splint or athletic tape to reposition the toes.
- Avoid shoes with heels over two inches.
- Wear soft shoes with plenty of room for the toes.
- Give your toes a workout by using them to pick up small objects such as marbles or a crumpled towel.
Rigid Claw Toe
“Rigid claw toe” designates the later stages in which the toes are fixed in this unnatural position. As the tendons tighten and the deformity becomes fixed, fewer options are available. Non-surgical treatments are confined more to pain-management than to correcting the condition. To minimize discomfort for rigid claw toe, the AAOS recommends trying specialized shoes “that have an extra 3/8” depth in the toe box” or asking a “shoe repair shop to stretch a small pocket in the toe box to accommodate [the toes].”
Katherine Ware, a stroke survivor, recommends a different option: surgery. “I’d be on a cane if it weren’t for the surgery,” she said. The procedure involved cutting the tightened tendons. Other possible procedures include lengthening or repositioning tendons, or shortening the bone of the toe. Inserting a steel pin into the toe often corrects the problem.
As with all surgeries, infection is a risk, and swelling and pain are common in the following weeks. Ware says her surgery was “easy” with a “quick recovery.” Although typically no tests are needed to identify claw toe, an X-ray will most likely be required if surgery is considered.
Botulinim toxin (Botox®) as Treatment
Botulinim toxin (Botox®), a complex protein byproduct of the bacterium famous for contaminating canned goods and homemade preserves, is another treatment option. Botulinim toxin has the highest toxicity of all known substances, so it seems odd that it has found its way to the forefront of medical technology. But the toxin, injected in tiny amounts at the site of the over-contracted muscle, has given relief.
For a muscle to contract, it must receive a chemical signal (neurotransmitter) from a nerve ending. Botulinim toxin injections block the nerve endings. This keeps the neurotransmitters from reaching the nerve and signaling the muscle to contract. The effects aren’t usually noticed for five to 10 days and last only three to four months.
Not much is widely know about claw toe, but you can get help for this painful condition. If your doctor doesn’t know much about it, seek more help, and ask more questions.
- Lillian Schwartz, a stroke survivor in Boca Raton, Fla., uses foam toe separators. Available at beauty supply stores for just a few cents, the separators are used by beauticians when giving pedicures. Schwartz recommends using two separators (one on top of the other) if your toes are long.
- James Pribish, a stroke survivor from New Castle, Del., uses a pair of gel insoles with tiny magnets embedded in them, which he says have greatly reduced the curling.