How To Conquer Crossover Second Toe Syndrome

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Insights On Grading Crossover Second Toe Syndrome

A grading system is essential in considering complaints associated with the deformity and arriving at proper treatment options. I have started to grade the crossover second toe prior to the toe actually crossing the hallux. In fact, my grading system considers the function of the plantar plate as the essential factor in assessing crossover second toe syndrome. As the grade level increases, the level of pain associated with the plantar plate decreases. This is mainly due to the fact that the partial rupture of the plantar plate progresses to a complete rupture.

• Grade I: No gross deformity with pain on the plantar second MPJ and no dorsal drawer sign noted.

• Grade II: Minimal medial deviation of the second toe with associated pain plantar to the second MPJ and a positive dorsal drawer sign. You’ll also see increased radiographic joint space of the lateral second MPJ in comparison to the medial aspect of the second MPJ. There may also be a possible hallux valgus deformity.

• Grade III: Dorsal displacement of the second toe at the MPJ with slight abutment or minimal crossover of the second toe dorsal to the hallux. The patient may have pain or no pain on the plantar surface of the second MPJ and a positive drawer sign. In addition to seeing an increased radiographic joint space on an antero-posterior radiograph of the lateral second MPJ with medial deviation of the second toe, a hallux valgus deformity is probable in these cases.

• Grade IV: Dislocation of the second MPJ with complete overriding second toe. The patient may have pain or no pain, but will usually have a hallux valgus deformity.

Here is a preoperative view of the crossover second toe, which has a complex etiology, according to the author.
Here is a typical radiograph of crossover second toe syndrome. Note the long second metatarsal and deviation of the second toe.
Here is an MRI that reveals a torn plantar plate with a fleck fracture from the base of the metatarsal.
Here is a surgical example of metatarsal osteotomy, flexor tendon transfer and fusion of the proximal interphalangeal joint.
By Babak Baravarian, DPM

Before testing the local deformity, first identify any structure that will make reduction of the second toe difficult. Often, there is an associated hallux valgus deformity and possibly adducted third and fourth toes which may be taking space in the location of the second toe. In cases in which you suspect a plantar plate tear of the second MPJ, consider possible laxity of the first ray or dynamic increased length of the second metatarsal. (Address these factors at the time of surgical correction of the crossover second toe.)
Then direct your attention to the second toe. Check the plantar MPJ of the second toe with direct pressure. Place pressure directly plantar to the second MPJ and it does not have to be very strong to illicit pain. As you move the area of pressure away from the metatarsal head and closer to the second toe, the level of patient discomfort should increase. This is due to the fact that most plantar plate tears are found to be off the base of the proximal phalynx.
Then check the second toe to determine the looseness of the plantar structures. Check the plantar plate with a dorsal drawer test. This is the single most important test in grade II and some grade III cases. If there is pain and dorsal puckering of the second MPJ with dorsal pull of the second toe, consider a plantar plate tear as the primary diagnosis until ruling it out.
Finally, check the crossover second toe for dorsal tightness of the joint capsule, extensor tendon and skin. In progressive deformity cases, it is not rare to have extremely tight skin in the region of the second MPJ and you must consider this factor since it may be necessary to perform skin lengthening at the same time as surgical correction of the underlying problems.
Radiographic examination is also very useful for proper diagnosis and treatment of the second toe symptoms. Be sure to consider adjacent structures in order to clear room for proper positioning of the second toe. In cases of hallux valgus deformity, you must also consider elevation of the first metatarsal. Additionally, you should visualize the position of the second toe in both a sagittal and transverse plane.
Finally, consider evaluation of second metatarsal length in comparison to adjacent metatarsals. It is very difficult to ascertain what is a long metatarsal and what is not, yet it is important to make sure that the second metatarsal is not far out of line in comparison to the other metatarsals.

What About Conservative Treatment Options?
Treatment of the crossover second toe is somewhat grade-dependent, although there is a great deal of overlap. In all cases, attempt conservative care for a period of time prior to planning any surgical correction. Conservative care is fairly easy in grade I cases and works very well most of the time. Begin by applying simple taping over the second toe with half-inch wide paper tape, as close to the MPJ as possible. Once the toe is in the ideal position, pull the tape onto the plantar arch region. In order to avoid strangulating the toe, do not cross the tape too close to the toe on the plantar surface.
An alternative treatment, but one which does not seem to work as well, is using a prefabricated device with an elastic strap and a plantar flat surface to hold the toe in the ideal position. You would combine this with stiff shoes and an orthotic device in cases of poor metatarsal length and/or laxity of the first ray. You may further customize the orthotic with a metatarsal pad or an accommodation plantar to the second metatarsal head, if you deem it necessary.
If treatment is not successful, consider a five-day course of oral steroid therapy which you may combine with physical therapy in order to resolve the inflammation and possible partial tear of the second MPJ plantar plate. When patients are not improving with stiff shoes, a below the knee walker or surgical shoe is an excellent option. Resolution of symptoms is supported with orthotic use and shoe changes.

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