What is 2nd toe joint instability? Ligaments that surround the 2nd toe joint form a capsule with fluid inside the capsule. Instability occurs when one of the ligaments surrounding the joint become “inflamed” or torn. Instability may also be referred to as pre-dislocation syndrome where the toe joint can become dislocated or an “overlapping toe.”

What causes pre-dislocation syndrome? Usually the ligament tear or joint dislocation occurs due to abnormal biomechanics on the joint from repetitive pressure. Some foot conditions will enhance the abnormal pressure on the 2nd toe joint. These conditions include bunions, long second toe (long 2nd metatarsal), tight calf muscle, and a flexible flatfoot. Although trauma is less common, acute trauma may lead to rupture of plantar plate ligament.

What are the symptoms? Typically pain, swelling, a “marble or balled up sock sensation” below the 2nd toe joint and most obvious is an overlapping 2nd toe. The symptoms start and progressively get worse. Early diagnosis is imperative to prevent progression of the injury. The overlapping 2nd toe is the end stage of pre dislocation syndrome and plantar plate ligament rupture.

Differential Diagnosis? Accurate early diagnosis is imperative for treatment. Morton’s neuroma, stress fracture, and capsulitis are common differential diagnoses. A physical exam from a foot and ankle surgeon, xrays, including ultrasound and MRI are useful tools to accurately diagnose the condition.

Conservative vs Surgical treatment? Conservative treatment is best in the early stages of symptoms before the 2nd toe begins to drift. Boot immobilization, NSAIDS, steroid injection, taping, and custom orthotics are all effective options. Surgery is indicated when the second toe has drifted and pain / immobility continues to progress despite conservative treatment. There are multiple procedures available for stabilizing the 2nd toe joint, your foot and ankle surgeon will decide on the most appropriate for your needs.


Kevin C. Bryant, DPM FACFAS

Diplomat, American Board of Foot and Ankle Surgery

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