Page 20 - 2021 Winter CMTA Report

The Surgical Correction of the CMT Foot:
IS SURGERY RIGHT FOR YOU?

PART 4 OF 4:

It Starts (and Ends) with the Toes

BY GLENN B. PFEFFER, MD

his is the last in our
series on CMT foot
surgery. I’ve saved the
toes for last, but per-
T haps they should have
been first, as they are the first
affected by CMT neuropathy.
Someone once wrote, “Toes are
at the end of your feet, but the
start of your journey,” and that
is certainly true when it comes
Dr. Pfeffer is an to CMT.
orthopedic foot and
ankle surgeon and CMT is a length-dependent
co-director of the neuropathy, which means that
CMTA’s Center of the muscles farthest away from toe as an early sign of CMT foot “brush, brush, brush.” I tell my
Excellence at Cedars-
Sinai Medical Center, the spine are affected first. The involvement, although there is CMT patients with toe problems
Los Angeles. He is small muscles in the foot are no telling whether it will worsen. to “stretch, stretch, stretch.”
also a member of the therefore the first to weaken. It is important to recognize Just like brushing, keep up the
CMTA’s Advisory stretching for the rest of your
Board. These small intrinsic muscles early on what is going on with
stabilize the toes, keep them the toes, as stretching exercises life. Even if you already have
straight and help them move in a may help prevent a fixed con- some fixed contractures of
coordinated fashion. As these tracture of the toe joints so that the joints (where they won’t
small muscles atrophy, the toes surgery can be avoided. straighten completely), a stretch-
start to curl into what is com- The stretching program is ing program may help prevent
monly referred to as a “clawed” quite simple: Stretch each of further progression.
position (shown below). the toe joints out into a straight Sometimes even the best
At first, the toes remain flex- position. If the middle joint stretching program doesn’t stop
ible, but over time they become (proximal interphalangeal joint) the toes from getting worse. It’s
fixed in their clawed position. It is flexing down, stretch it important to understand what is
is often the baby toe (fifth toe) straight. If the metatarsal-pha- going on in this situation. The
that starts to deform first. Par- langeal (MTP) joint at the base foot intrinsic muscles, as we dis-
ents who are concerned about of the toe is extending up, cussed, are usually affected first
their children’s feet might watch stretch it down. Do the same with CMT, but the tibialis ante-
out for this clawing of the fifth thing with all of the other joints. rior (TA) is often not far behind.
Hold the joint straight for 10 The TA is the large muscle in the
seconds once or twice a day. A anterior leg that lifts the ankle.
physical therapist can help you The toe extensor muscles also
make sure you are stretching the contribute to lifting the ankle
right way. It shouldn’t take more (dorsiflexion).
than one or two visits to help set You can see that when a
you up with a home program. normal ankle goes up, the toes
Clawed toes My dentist used to tell me to go up as well. Once the TA starts

20 THE CMTA REPORT WINTER 2021