Claw Toes: Targeted Exercises, Silicone Orthoses and Daily Relief

What lies behind it

The anatomical structure of our toes is based on a delicate interplay of bones, tendons, ligaments, and muscles. Each of the lesser toes, from the second to the fifth ray, consists of three phalanges: the proximal phalanx (Phalanx proximalis), the middle phalanx (Phalanx media), and the distal phalanx (Phalanx distalis). These are connected to one another via three functional joints. The metatarsophalangeal joint connects the proximal phalanx to the metatarsal bone. The proximal interphalangeal joint connects the proximal and middle phalanges, whereas the distal phalanx is attached via the distal interphalangeal joint.

In a claw toe (Digitus flexus), a biomechanical imbalance exists between opposing muscles. Normally, the extensor digitorum longus and extensor digitorum brevis tendons hold the toes in a slightly upright position. The flexor digitorum longus and flexor digitorum brevis tendons ensure a powerful push-off during walking. A crucial role is played by the intrinsic foot muscles, particularly the lumbrical and interosseous muscles (Musculi lumbricales and Musculi interossei). These small muscles flex the toes at the metatarsophalangeal joint while simultaneously extending the proximal and distal interphalangeal joints.

If the stabilising function of these intrinsic foot muscles fails or the pull of the long extensor tendons decisionally predominates, the system tips out of balance. A characteristic hyperextension occurs at the metatarsophalangeal joint. The base of the proximal phalanx shifts upwards. In response, the proximal and distal interphalangeal joints adopt marked flexion. The toe curls into a claw-like position. In advanced stages, the fat pad that normally protects the metatarsophalangeal joint from pressure shifts distally. The metatarsal head region is pressed unprotected against the ground, causing substantial weight-bearing pain.

Typical signs

The most prominent feature of a claw toe is constant flexion at both the proximal and distal interphalangeal joints, combined with hyperextension at the metatarsophalangeal joint. It is essential to distinguish claw toe from other toe deformities. In a classic hammertoe, flexion occurs at the proximal interphalangeal joint, while the distal interphalangeal joint remains extended or hyperextended. In a mallet toe, only the distal interphalangeal joint is flexed. An overlapping toe, in turn, describes one toe resting on top of another, often as a result of severe hallux valgus.

Typical complaints initially manifest through mechanical friction inside footwear. Due to persistent pressure from shoe leather, painful calluses quickly form over the flexed proximal interphalangeal joint. From this, a hard corn (Clavus durus) frequently develops. A painful area of hyperkeratosis or thinning skin also forms at the tip of the toe due to constant contact with the ground. Affected individuals report a dull burning sensation in the forefoot area, occurring primarily during weight-bearing activities.

A practical case example illustrates the progression: a 58-year-old female patient presented with persistent pain at the tip of the second toe on her left foot. She reported that walking on hard surfaces without cushioned footwear was barely possible anymore. Examination revealed a rigid flexion posture at the proximal interphalangeal joint accompanied by a thick hyperkeratotic plaque on the distal phalanx. The altered pressure distribution had already led to an altered gait pattern with antalgic limping. Through a combination of callus debridement, a customized silicone orthosis, and daily self-directed exercises, her walking distance was extended pain-free within six weeks.

Everyday causes

The causes of claw toes are multifaceted and often interconnected. Inappropriate footwear ranks highest among these factors. Overly tight, pointed shoes compress the toes longitudinally. High heels exacerbate the problem significantly: body weight shifts forward onto the forefoot. The toes are pressed against the toe box and mechanically forced into a flexed position. Over years, this causes the flexor tendons to shorten and the joint capsules to contract.

Another central factor is existing foot architecture. A pronounced splayfoot (metatarsus latus), in which the anterior transverse arch collapses, alters the vector direction of tendon pull. Similarly, in a high-arched foot (pes cavus), the toes are under high baseline tension, promoting the development of claw toes. The impact of systemic or neurological underlying conditions should not be underestimated. Diabetes mellitus frequently leads to atrophy of the intrinsic foot muscles via peripheral polyneuropathy. The loss of tone in these intrinsic muscles allows the long tendons to dominate, causing the toes to curl.

Rheumatoid arthritis insidiously destroys joint capsules and ligaments, leading to instability at the metatarsophalangeal joint. Balance within the foot is also altered after trauma, such as suboptimally healed metatarsal fractures, or due to age-related loss of muscle mass. Incorrect toenail trimming techniques or neglected skin care are not direct causes of the deformity, but they significantly aggravate irritation and inflammatory processes within footwear.

When medical evaluation is necessary

Although many relief measures and conservative therapies can be initiated directly, clear medical warning signs exist. Immediate specialist evaluation by an orthopaedic surgeon or dermatologist is required if the following symptoms occur:

• Acute redness, localized warmth, or swelling around the toe joints, indicating bursitis or joint inflammation.
• Open skin areas, blisters, or ulcers, particularly in patients with diabetes mellitus or peripheral arterial disease.
• Sudden onset of numbness, tingling, or complete loss of sensation in the toes.
• Complete joint rigidity, where the toe can no longer be manually straightened into a normal position.
• Resting pain that occurs independently of weight-bearing or footwear and disturbs sleep.

In such cases, it must be clarified whether infectious processes, severe circulatory disorders, or advanced bony remodelling are present. Podiatric treatment can only be continued safely following medical clearance or in close consultation with a physician.

What podiatric treatment can achieve

Professional podiatry offers a broad spectrum of non-invasive measures to alleviate pain and support foot function. The treatment process begins with a thorough medical history and visual assessment of the foot. This serves to evaluate whether the deformity is still flexible, semi-rigid, or already completely fixed. An individualized treatment plan is formulated on this basis.

A central component is comprehensive podiatric treatment (podologische Komplexbehandlung). Painful hyperkeratosis and corns over the proximal interphalangeal joints or toe tips are professionally and painlessly debrided. Scalpel-like instruments and rotating burs are used for this purpose. The skin is polished smooth to minimize peak friction. In addition, nail plates are trimmed and managed so that no additional pressure is exerted on the nail bed.

A highly effective tool in podiatry is the fabrication of custom silicone orthoses. These pressure- and friction-relieving devices are molded directly on the patient's foot using medical-grade two-component silicones. Depending on the therapeutic goal, different hardness levels (Shore A 15 to Shore A 30) are used. Soft silicone serves purely for pressure relief and cushioning of sensitive areas. Slightly firmer silicone is used to gently correct flexible deformities and guide the toe into a more extended position. The orthoses are worn inside the shoe during the day and are easy to clean.

Additionally, specialized taping techniques can be employed to centre the metatarsophalangeal joints and relieve strain on the plantar fascia. As a sectoral practitioner for podiatry (sektorale Heilpraktikerin für Podologie), the podiatrist can also independently make diagnoses and prescribe podiatric therapies, significantly shortening the care pathway. Treatment intervals typically range from four to six weeks to continuously monitor hyperkeratosis and inspect the fit of orthoses.

What you can do yourself

Active participation of the patient is critical for long-term success. To counteract tendon shortening and strengthen intrinsic foot musculature, targeted claw toe exercises should be performed daily. A structured exercise program takes only a few minutes, but requires consistency.

1. Janda's Short Foot: Sit on a chair with your feet flat on the floor. Attempt to pull the ball of the forefoot towards the heel without curling the toes. The foot arch visibly and palpably elevates. Hold the tension for five seconds and release slowly. Repeat ten times per foot.
2. Active toe spreading: Lift your toes slightly off the ground. Try to separate all toes as far from one another as possible, similar to spreading your fingers. Hold the spread for three seconds and place the toes down wide. This exercise strengthens the interosseous muscles.
3. Passive flexor tendon stretching: Grasp the curled toe with your fingers from underneath. Gently pull the toe long without causing pain and bring the proximal interphalangeal joint into an extended position. Hold this stretch for 20 to 30 seconds. This helps keep the contracted joint capsule pliable.
4. Hand-foot grip: Interlace the fingers of one hand between the toes of the affected foot. Gently rotate the toes in circular motions. This improves mobility in the metatarsophalangeal joints and promotes blood circulation.

Alongside active exercises, night splinting plays an important role. During sleep, muscles relax, and flexor tendons tend to shorten further in the curled posture. A nocturnal positioning splint or specialized silicone night orthoses gently hold the toes in a neutral, extended position. This prevents nocturnal consolidation of the contracture and complements the daytime regimen optimally.

Additionally, footwear selection must be critically evaluated. Shoes should feature a wide toe box so that toes have sufficient room in both length and width. Heel height should not exceed two centimetres. Soft, seamless upper materials prevent additional pressure points.

Common errors

In clinical practice, certain behaviours repeatedly worsen the condition of the toes unintentionally. To prevent setbacks in therapy, the following mistakes should be consistently avoided:

• Use of rigid toe separators while walking: Ill-fitting, excessively hard toe spacers or foam wedges inside shoes can massively increase pressure on adjacent toes and compress nerves. Pressure protection must always be individually customized.
• Aggressive callus removal: Attempting deep self-removal of calluses over joints using blades, planes, or pumice stones frequently causes micro-trauma. The skin responds to the irritation with accelerated hyperkeratosis or inflammation.
• Exclusive stretching without strengthening: Stretching flexor tendons without strengthening weakened foot muscles fails to produce lasting stability. The muscular imbalance persists.
• Ignoring early stages: As long as the toe can still be passively extended, correction potential is highest. If patients wait until joints become stiffened by bony changes, often only pressure-relieving or surgical options remain.

Current evidence and medical consensus

Scientific literature clearly supports the efficacy of conservative therapeutic approaches for flexible toe deformities. Studies on foot biomechanics demonstrate that targeted strengthening of intrinsic foot muscles (especially the lumbrical muscles) improves plantarflexion at the metatarsophalangeal joint and reduces load on the metatarsal heads [1].

Clinical studies examining the use of custom-fabricated silicone orthoses demonstrate significant pain reduction in patients with metatarsalgia and claw toes [2]. The orthoses redistribute plantar pressure away from painful joint heads toward relieving zones. Comparative studies highlight that a combination of physical therapy, targeted movement exercises, and pressure relief can effectively slow the progression of semi-rigid deformities [3].

Systematic reviews regarding assistive devices emphasize the importance of nocturnal splinting. Nocturnal stretching of the capsuloligamentous apparatus helps maintain passive mobility of the proximal interphalangeal joint over longer periods [4]. Nevertheless, researchers note that in completely rigid, fixed contractures, conservative measures primarily serve pain relief and wound prevention, whereas structural realignments are often reserved for surgical procedures [5].

Treatment in Memmingen

At our practice FREITAG® Podologie GmbH in Memmingen, we offer comprehensive and expert care for all forms of toe deformities. Under the direction of Helga Maria Freitag, state-recognised podiatrist and sectoral practitioner for podiatry (sektorale Heilpraktikerin für Podologie), we precisely analyse your foot statics and develop tailored treatment plans.

Whether fabricating custom silicone orthoses, painlessly debriding painful hyperkeratotic structures, or providing guidance on targeted claw toe exercises for home use: we support patients from Memmingen, the Unterallgäu, Upper Swabia, and the entire Allgäu region. Modern adjunctive procedures such as cryotherapy can also be used for inflammatory concomitants. If you have questions or would like to schedule an appointment, please feel free to contact us directly.

Orthotic provisions and footwear modification

When conservative stretching exercises and silicone orthoses reach their limits, targeted orthopaedic insoles form the mechanical backbone of pain relief. The primary biomechanical goal is to elevate the collapsed transverse arch structure of the forefoot and relieve overloaded metatarsal heads II through IV. A custom-made retrocapital pad (metatarsal dome) is used for this purpose. This teardrop- or butterfly-shaped pad made of firm polyurethane foam is positioned precisely behind the heads of the metatarsal bones. It passively corrects the malalignment during heel-strike and stance by redistributing pressure to adjacent soft tissues.

In advanced symptoms, a simple insole is often no longer sufficient. In such cases, specialized forefoot cushioning pads made of synthetic materials with low Shore hardness (approximately 15 to 20 Shore A) are utilized. These cushions reduce localized peak pressure by up to 40 percent. Additionally, footwear modifications to the outsole may become necessary. Sole stiffening combined with a slightly retro-positioned rocker sole relieves bending stress from the toe joints. The foot rolls over the sole curvature without requiring flexion of the metatarsophalangeal and proximal interphalangeal joints.

Shoe fit must be strictly aligned with these assistive devices. Many individuals make the mistake of inserting insoles into overly narrow off-the-shelf shoes. This drastically reduces internal volume, further increasing pressure on the dorsal aspect of the clawed toes. A shoe model featuring an enlarged toe box, a shallow heel-to-toe drop of ten millimetres at most, and a removable insole is required. Digital pedobarography, the measurement of pressure distribution during gait, visualizes peak forces and enables precise fine-tuning of the orthopaedic device.

Surgical procedures and postoperative care

If a claw toe can no longer be mobilized through conservative measures and persistent contact pain or skin defects remain, surgical correction is considered. The selected surgical technique depends strictly on the degree of flexibility of the contracture and the status of the metatarsophalangeal joint. For deformities that remain partially flexible, a Girdlestone-Taylor flexor-to-extensor tendon transfer can be performed. In this procedure, the flexor digitorum longus tendon is redirected onto the extensor hood. The muscle pull is thereby reversed, actively supporting extension of the proximal interphalangeal joint.

Conversely, if a rigid, bony fixed contracture is present, Hohmann resection arthroplasty represents the most widely used standard procedure. The surgeon removes the head and neck portion (proximal third) of the proximal phalanx. This relaxes the shortened joint capsule, allowing the toe to be realigned smoothly. For temporary stabilization, a thin 1.2 mm Kirschner wire is often inserted longitudinally through the phalanges for four to six weeks. Alternatively, modern, flush-fitting intramedullary implants made of titanium or nitinol are used; these remain inside the bone and eliminate the need for external wire fixation.

The postoperative rehabilitation phase demands patience and disciplined wound care from patients. During the first four to six weeks following surgery, patients wear a specialized forefoot offloading shoe. This surgical shoe prevents forefoot roll-off and protects bone healing. Following wire removal or osseous consolidation, podiatric and physical therapy follow-up care begins. Tissue flexibility is restored through gentle mobilization techniques, scar care massages, and targeted decongestive therapies such as manual lymphatic drainage. Premature weight-bearing in narrow standard shoes carries the risk of recurrent contractures or wound healing impairment.

Special considerations in diabetes and rheumatoid conditions

In individuals with diabetes mellitus or rheumatoid arthritis, the presence of claw toes demands heightened vigilance. The diabetic foot is often characterized by peripheral sensory polyneuropathy. Nerve damage results in friction, pressure points, and even deep corns not being perceived as pain by the brain. Affected individuals simply do not feel the tight shoe or friction spot over the proximal interphalangeal joint. Left untreated, seemingly minor blisters can develop within days into deep tissue defects, including diabetic foot ulcers.

Regular self-inspection of the feet is therefore an essential daily routine for diabetic patients. A hand mirror or telescopic mirror helps easily inspect the undersides of the toe tips and the interdigital spaces. Additionally, podiatric assessment must include testing vibration perception using a neurological tuning fork and evaluating surface sensitivity with a Semmes-Weinstein monofilament. If testing reveals reduced sensitivity, sharp-edged instruments must never be used at home. Care should be limited to mild urea-containing creams with a urea concentration of five to ten percent.

In rheumatoid arthritis, chronic joint inflammation systematically destroys the capsuloligamentous apparatus of the midfoot and forefoot. This often results in a combination of claw toes, hallux valgus, and destructive subluxation of the metatarsophalangeal joints. The delicate pannus tissue within the joints is extremely sensitive to mechanical pressure. Pressure relief at this stage must be particularly soft and broad in area. Seamless socks made of silver thread constructions or fine microfibre textiles prevent additional friction pain, while custom orthopaedic shoes or therapeutic shoes provide the necessary spacious protection for often severely deformed feet.