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Crossover Second toe (Predislocation Syndrome)

                  



What is Crossover Toe?
Crossover toe is a condition in which the second toe drifts toward the big toe and eventually crosses over and lies on top of the big toe.  The condition is usually seen in adult females, although can occur at any age, male of female. 

Crossover toe is similar in appearance to a hammer toe, but other than appearance, this is a completely different issue.  This issue is a much more complicated problem than a hammertoe.  Hammertoes generally contract only in the sagittal plane (up and down) where as the crossover toe deformity is deviated in several different planes. Due to these properties, this is a more complicated problem.

Etiology:
This is a biomechanical deformity which results from abnormal mechanics of the foot.  Normally, there is an even distribution of weight across all of the metatarsal heads in the foot (the bones at the base of the toes.)  Some people carry too much weight on the second metatarsal head and joint (metatarsophalangeal joint) and this is where the probelm originates.  Over time the stress in this location leads to weakening of the ligaments and capsule of this joint.  Although this may begin as an isolated pain, over time the structures stretch out or rupture and the deformity occurs.  As you can imagine - the more these structures stretch or tear, the worse it gets.  This is a progressive deformity meaning that the longer it is not addressed, the worse it gets and the more challenging it is to repair.  The Darco foot spint is excellent for conservative treatment....this may prevent surgery.  Or if you need surgery, this will allow it to heal in the ideal position.

                                             

Conditions that are also seen with a crossover toe deformity include a significant bunion deformity, an elongated second metatarsal, and a hypermobile foot type with a collapsing arch.  A condition called equinus or tight calf muscles can lead to worsening of this deformity due to an increased amount of stress placed on the front part of the foot.

In addition to the above mentioned splint, which will most likely be useful at night or while at rest, the toes can be splinted together with tape or band-aids.  The problem with this is that often times the adhesive properties of tape or band-aids will often cause skin irritation, as this is a long term issue.  The splints seen below can help to keep the toes aligned (Digit Wrap or Dr. Jill's Double Hammertoe Splint)and are much better for the skin.

                           



Symptoms:
Generally pain in the bottom of the foot under the second toe is one of the initial complaints.  Often shoe wear becomes difficult as the second toe changes shape and is constricted and rubs inside the shoe.  Swelling is seen under the toe and sometimes over the top of the toe where it rubs in the shoe.  For someone without adequate sensation, this can become a significant risk for an ulceration and subsequent bone infection.

Treatment Options:
Initially this problem can be treated very effectively non-surgically.  Stabilizing this joint by strapping the toe "down and over" can allow this to heal before it starts to deviate too much towards the big toe or even overlap the big toe.  Shoe modifications, orthotics, and stretching may help to alleviate the pain. 

Until you are able to be examined by a doctor, the “R.I.C.E.” method should be followed. This involves: 

  • Rest. It is crucial to stay off the injured foot, since walking can cause further damage. Non-weightbearing with crutches or a walker is ideal. For immobilization, a CAM walker is often recommended.   If surgery is necessary, the CAM walker will be used during the post-operative recovery period.  Often times a foot and ankle specialist may try to immobilize you in a CAM walker for 6 weeks prior to performing any surgery to see if this injury will heal on its own first.  A surgical shoe can help to immobilize this joint to a lesser extent, but will still be much better than normal shoes - it will reduce motion at this joint.
  • Ice. To reduce swelling and pain, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
  • Compression. Wrap the ankle in an elastic bandage or wear a compression stocking to prevent further swelling.  An ACE bandage is often recommended as initial treatment.
  • Elevation. Keep the foot elevated to reduce the swelling. It should be even with or slightly above the hip level.  


Surgical Options:
Once this toe has changed positions, it will not bo back to a normal shape wthough a surgical procedure.  Unless this deformity is causing significant pain or is causing difficulty with shoewear, surgery should always be delayed a long as possible.  There are several different ways to fix this deformity, and most require forms of screw and/or wire fixation to hold the correction while the bones and soft tissues heal.  If this deformity continues to change shape, you may develop a dislocated second metatarsophalangeal joint (MPJ) which is even more difficult to repair.  Click here for our information on dislocated second MPJ deformity.  

What to expect with a surgical correction:
Surgical correction is aimed at ultimately relieving pain at this joint and making the toe remain much straighter.  The toe is likely to need a fusion to maintain this straight position.  A fusion is a common procedure to correct significant toe deformities.  With the fusion, the toe will not bend in the middle anymore but will remain straight as intended.  There will probably be a wire extending through the end of the toe to maintain this position for 4-6 weeks.  Additionally, the toe and MPJ will remain stiff for between 6-12 months after surgery and may not bend up and down at the MPJ as well as it did prior to surgery.  The toe may drift slightly back towards the big toe over time.  To help maintain position after surgery for up to several months, a toe splint is hightly recommended - click here to see the Darco toe alignment splint.  It is important to remember that this deformity is being corrected because of pain and because the toe is crossing over the big toe.   We are also trying to correct this deformity prior to a dislocation of the 2nd MPJ which is much more complicated. With this type of deformity, surgical results vary greatly from patient to patient. 
 
    

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