Second Toe Plantar Plate Tear | Dorsal Dislocation | Flexible vs Rigid
- Plantar plate tear at second MTP is the primary pathology - loss of plantar restraint allows dorsal subluxation
- Hallux valgus is the underlying cause in 80% - great toe pushes second toe dorsally and medially
- Crossover occurs over the hallux - second toe crosses medially over great toe in severe cases
- Flexible vs rigid determines treatment: flexible = soft tissue repair, rigid = bone procedure
- Weil osteotomy shortens metatarsal to reduce tension, combined with plantar plate repair
- “Long second metatarsal (Morton foot) predisposes to plantar plate overload and tear
- “Paper pull-out test: inability to grip paper with toe indicates plantar plate incompetence
- “Lachman test of MTP: dorsal translation over 2mm suggests plantar plate rupture
- “MRI shows plantar plate tear as high T2 signal at insertion on proximal phalanx base
Clinical Imaging
Imaging Atlas
Key Mnemonics
The visible crossover is a late sign. The reparable window is the earlier "predislocation" stage — plantar second MTP pain and a positive dorsal drawer sign before fixed deformity. Once the joint dislocates and becomes rigid, soft-tissue repair fails and the patient needs a fusion. Examine the drawer sign in any older woman with unexplained forefoot pain.
CROSSOVERCauses / Predisposing Factors
Hook:The deformity name spells out its own risk factors - end with the second ray taking the greatest load.
WPFEHFive Components of Flexible Reconstruction
Hook:Work Properly From Each Heel - the H (hallux valgus correction) is the one most often forgotten and the commonest cause of recurrence.
DRIPClinical Examination Sequence
Hook:DRIP starts with the Drawer because the dorsal drawer sign is the most specific test (specificity ~100%).
Overview and Epidemiology
Crossover toe deformity is a transverse-plane malalignment of the second toe, which deviates medially and dorsally to lie over the hallux. It is the end-stage manifestation of lesser metatarsophalangeal (MTP) joint instability driven by attritional failure of the plantar plate — the principal static stabiliser of the MTP joint. Earlier, pre-deformity inflammatory stages are described by podiatric authors as "predislocation syndrome."
- Sex: Strongly female-predominant (86% women in the largest surgical cohort)
- Age: Peak incidence in women over 50; mean age at surgery ~59 years
- Associations: Hallux valgus, first MTP degenerative arthritis, inflammatory arthropathy (RA), high heels and constrictive footwear
- Ray affected: Second MTP most commonly (longest lesser ray, greatest load)
- Primary lesion: Plantar plate tear at the proximal phalangeal insertion
- Driver: Hallux valgus removes the lateral buttress, allowing medial drift
- Stabilisers lost: Plantar plate (sagittal) and lateral collateral ligament (transverse)
- End result: Dorsal subluxation then dislocation; EDL becomes deforming force
Pathophysiology and Mechanism
80% of crossover toe occurs with hallux valgus. The deviated great toe exerts medial and dorsal force on the adjacent second toe. Over time, this chronic pressure overloads the plantar plate at the second MTP, causing it to tear. Correcting hallux valgus is essential - if you repair the crossover toe without addressing the hallux valgus, the deformity will recur.
Progressive Pathophysiology
Great toe deviates laterally (valgus). The hallux occupies more medial space and pushes against the second toe. This increases mechanical stress on the second MTP plantar plate.
Chronic overload causes microtrauma to the plantar plate (fibrocartilaginous structure on plantar aspect of MTP). The plate develops partial tears, usually at its insertion on the proximal phalanx base.
Full-thickness plantar plate rupture occurs. Loss of plantar restraint allows dorsal subluxation of the proximal phalanx. The EDL (extensor digitorum longus) now overpowers the plantar structures.
Combined forces: hallux pushes medially, EDL pulls dorsally. The second toe crosses over the great toe medially. Without treatment, the toe becomes rigid in this position due to capsular contracture.
| Factor | Mechanism | Clinical Significance |
|---|---|---|
| Hallux valgus | Great toe deviates laterally, pushes second toe medially and dorsally | Present in 80% - must correct to prevent recurrence |
| Plantar plate tear | Loss of primary plantar restraint at second MTP | Primary pathology - allows dorsal subluxation |
| EDL overpull | Extensor digitorum longus overpowers weakened plantarflexors | Contributes to dorsal subluxation - requires lengthening |
| Long second metatarsal | Increased mechanical stress on second MTP plantar plate | Anatomical variant predisposing to tears - may need Weil shortening |
| Intrinsic muscle atrophy | Loss of lumbricals and interossei function with age | Weakens plantar flexion - FDL transfer restores balance |
Classification - Coughlin Clinical Staging
| Stage | Deformity Characteristics | Reducibility | Treatment |
|---|---|---|---|
| Stage 1 | Medial deviation, mild dorsal subluxation | Fully flexible, passively reducible | Conservative: taping, orthotics, wide toe box shoes |
| Stage 2 | Moderate crossover, partial dislocation | Semi-rigid, partially reducible | Surgical: plantar plate repair + flexor transfer + Weil osteotomy |
| Stage 3 | Severe crossover, complete dislocation | Rigid, irreducible | Surgical: arthrodesis or resection arthroplasty |
The flexibility of the deformity determines surgical approach:
Flexible (Stage 1-2):
- Deformity corrects with passive manipulation
- Joint surfaces still congruent
- Soft tissue repair possible: plantar plate repair, flexor transfer, Weil osteotomy
- Goal: restore soft tissue balance and joint alignment
Rigid (Stage 3):
- Deformity fixed, will not reduce passively
- Joint surfaces incongruent or arthritic
- Soft tissue repair insufficient
- Requires bone procedure: arthrodesis (fusion) or resection arthroplasty
How to Determine Stage Clinically
Stage 1 (Flexible):
- Patient can actively straighten toe
- Passive reduction fully corrects alignment
- No fixed contracture of capsule or EDL
- MTP joint congruent on X-ray
Stage 2 (Semi-rigid):
- Cannot actively correct, but passive reduction partial
- Some capsular contracture present
- EDL tight (requires forced plantar flexion to reduce)
- MTP joint subluxed but not dislocated
Stage 3 (Rigid):
- Cannot reduce passively even with force
- Dorsal capsule severely contracted
- Complete MTP dislocation on X-ray
- May have secondary arthritis
This staging guides treatment selection.
Clinical Presentation and Examination
- Pain location: Plantar second MTP, worse with walking
- Deformity progression: Gradual onset over months to years
- Footwear difficulty: Cannot wear regular shoes, toe rubs dorsally
- Hallux valgus: Often reports bunion deformity
- Previous treatment: Often tried pads, wider shoes without relief
- Functional limitation: Difficulty with push-off, balance issues
- Inspection: Second toe crosses medially over hallux, dorsal subluxation
- Hallux valgus: Assess severity, intermetatarsal angle
- Reducibility: Attempt passive reduction to determine stage
- Paper pull-out test: Inability to grip paper = plantar plate incompetence
- Lachman test MTP: Dorsal translation over 2mm = plantar plate rupture
- Neurovascular: Ensure no digital nerve compression
Special Tests
| Test | Technique | Positive Finding | Significance |
|---|---|---|---|
| Paper pull-out test | Place paper under toe, ask patient to grip, pull paper out | Unable to hold paper (slips out) | Plantar plate incompetence - loss of plantar flexion strength |
| MTP Lachman test | Stabilize metatarsal head, dorsally translate proximal phalanx | Greater than 2mm dorsal translation | Plantar plate rupture - loss of plantar restraint |
| Passive reducibility test | Apply plantar and lateral force to reduce toe alignment | Flexible: fully reducible. Rigid: irreducible | Determines stage and surgical approach |
| Plantar ecchymosis | Inspect plantar surface of second MTP | Bruising present | Acute or subacute plantar plate tear |
Differential Diagnosis
| Condition | Key Features | Discriminators from Crossover Toe |
|---|---|---|
| Crossover toe (plantar plate tear) | Older woman, second MTP plantar pain, medial/dorsal crossover, positive drawer | Positive drawer sign, gradual deformity, hallux valgus association |
| Morton neuroma | Burning interdigital pain, Mulder click, numbness of adjacent toes | No fixed toe deformity, no drawer instability, sensory symptoms predominate |
| Freiberg disease | Adolescent/young adult, second metatarsal head osteonecrosis, joint flattening on X-ray | Osteochondral collapse on radiograph, painful dorsiflexion, no plantar plate drawer |
| MTP synovitis (inflammatory arthritis) | Bilateral, symmetric, multiple MTPs, raised inflammatory markers | Systemic features, serology positive, multi-joint involvement |
| Stress fracture of metatarsal | Activity-related dorsal pain, focal bony tenderness, callus on X-ray | Bony (not plantar) tenderness, no instability, history of overuse |
| Hammer/claw toe (isolated) | PIP flexion deformity without MTP crossover | Deformity at PIP not MTP, no medial drift, drawer negative |
The single most useful examination finding is the dorsal drawer (Lachman) test of the second MTP joint — it has a reported specificity approaching 100% for plantar plate insufficiency. A subtle, gradually progressive forefoot pain with a positive drawer in an older woman is plantar plate tear until proven otherwise, even before any visible crossover develops (the "predislocation" stage). Missing this leads to delayed referral and progression to a rigid, dislocated joint requiring fusion rather than reparable soft-tissue surgery.
Early surgical intervention indicated if:
- Rapid progression despite conservative treatment (under 3 months)
- Severe pain limiting daily activities
- Stage 2 deformity (semi-rigid) - prevents progression to rigid Stage 3
- Skin breakdown over dorsal toe from shoe pressure
- Patient motivated and medically fit for surgery
Delaying surgery in Stage 2 allows progression to rigid Stage 3, which has worse outcomes.
Investigations
Plain X-ray Assessment
Standard Views:
- AP weight-bearing foot: Shows hallux valgus angle, second MTP alignment
- Lateral weight-bearing: Shows dorsal subluxation of second toe
- Oblique foot: Additional detail of MTP joints
Key Measurements:
- Hallux valgus angle (normally under 15 degrees)
- Intermetatarsal angle (1-2, normally under 9 degrees)
- Second MTP alignment (subluxation vs dislocation)
- Relative metatarsal lengths (long second metatarsal)
Findings by Stage:
- Stage 1: Minimal subluxation, joint congruent
- Stage 2: Partial subluxation, joint surfaces losing contact
- Stage 3: Complete dislocation, proximal phalanx dorsal to metatarsal head
Weight-bearing films essential to assess true deformity.
Management Algorithm
The goal is to restore toe alignment and address the underlying hallux valgus. Stage 1 (flexible) can be managed conservatively. Stage 2 (semi-rigid) requires soft tissue reconstruction (plantar plate repair + flexor transfer + Weil osteotomy + hallux valgus correction). Stage 3 (rigid) requires arthrodesis or resection arthroplasty. Failure to correct hallux valgus results in recurrence.
Non-Operative Management
Indicated for:
- Stage 1 (flexible) deformity
- Mild symptoms, minimal functional limitation
- Patient not candidate for surgery
Interventions:
- Buddy taping: Tape second toe to third toe (prevents medial deviation)
- Wide toe box shoes: Reduces dorsal pressure on toe
- Metatarsal pads: Offloads second MTP
- Custom orthotics: Supports metatarsal arch
- NSAIDs: For pain and inflammation
Outcomes:
- 30-40% achieve symptom control
- Does not correct deformity, only prevents progression
- Most progress to Stage 2 and require surgery
Conservative treatment is temporizing for most patients.
Complications
| Complication | Incidence | Risk Factors | Prevention/Management |
|---|---|---|---|
| Recurrence | 10-20% | Hallux valgus not corrected, overcorrection avoided | Always correct hallux valgus concomitantly |
| Transfer metatarsalgia | 15-25% | Excessive metatarsal shortening (Weil osteotomy) | Limit shortening to 3-5mm, assess adjacent MTP joints |
| Stiffness | 10-15% | Arthrodesis, aggressive soft tissue dissection | Expected with fusion, ROM exercises if soft tissue repair |
| Floating toe | 5-10% | Excessive EDL lengthening, overcorrection | Balanced lengthening, avoid overcorrection |
| Nonunion (if arthrodesis) | 5% | Poor bone quality, smoking, inadequate fixation | Rigid fixation, smoking cessation, revision if symptomatic |
| Pin tract infection | Rare | K-wire fixation, poor hygiene | Pin care, early removal at 2-3 weeks |
Excessive metatarsal shortening from Weil osteotomy can cause transfer of pressure to adjacent metatarsals (third/fourth MTP). Limit shortening to 3-5mm. If patient develops new pain at adjacent MTP post-operatively, may require additional Weil osteotomies at those sites.
Outcomes and Prognosis
Prognostic Factors
- Stage 1-2 (flexible or semi-rigid)
- Hallux valgus corrected concomitantly
- Early surgical intervention (before rigid)
- Good bone quality for fixation
- Non-smoker, compliant with rehab
- Normal body weight
- Stage 3 (rigid) deformity
- Hallux valgus not addressed
- Inflammatory arthritis (RA)
- Previous failed toe surgery
- Obesity, smoking
- Excessive metatarsal shortening
Surgical Outcomes by Stage
| Stage | Surgery Type | Good-Excellent Result | Key Outcome Measures |
|---|---|---|---|
| Stage 1 (flexible) | Conservative or soft tissue repair | 85-90% | Pain relief, deformity correction, return to shoes |
| Stage 2 (semi-rigid) | Plantar plate repair + flexor transfer + Weil | 80-85% | Alignment restoration, functional improvement |
| Stage 3 (rigid) | Arthrodesis or resection arthroplasty | 65-75% | Pain relief (fusion reliable), stability |
Evidence Base and Key Studies
Original Crossover Second Toe Description
- Coined the term crossover second toe and described the deformity sequence: medial deviation progressing to dorsal subluxation crossing over the hallux
- 17 patients (22 toes); 11 patients (15 toes) treated operatively
- 90% satisfactory result at mean 42-month follow-up after soft-tissue correction
- Attributed the deformity to deterioration of the lateral collateral ligament and capsule of the second MTP joint
Demographics, Etiology and Radiographic Assessment
- 169 operatively treated patients: 86% women, mean age 59 years (peak incidence in women over 50)
- Increased incidence of hallux valgus and first MTP degenerative arthritis in the cohort
- Positive drawer (Lachman) sign was the most reliable and consistent physical examination finding
- Medial deviation of the second relative to third MTP angle was the most reliable radiographic indicator; no correlation with second metatarsal length or 1-2 intermetatarsal angle
Plantar Plate Anatomic Grading (Cadaveric)
- 16 cadaveric crossover-toe specimens dissected — largest such series
- Consistent transverse plantar plate tears immediately proximal to the proximal phalangeal insertion
- With greater deformity: wider distal transverse tears extending lateral-to-medial, then midsubstance and collateral ligament tears
- Basis for the anatomic (intra-operative) grading system 0-IV used to guide surgical technique
Clinical Examination Diagnostic Accuracy
- 90 patients (109 feet) with intra-operatively confirmed plantar plate tears
- Drawer (Lachman) sign: sensitivity 80.6%, specificity 99.8% — the single most useful test
- Crossover toe specificity 88.9% for an underlying plantar plate tear
- 95% presented with gradual-onset forefoot pain plus second metatarsal-head edema
Exam Viva Scenarios
Practise clinical reasoning and management decisions out loud
“A 55-year-old female presents with progressive second toe deformity and pain. She has moderate hallux valgus and the second toe crosses medially over the great toe. The deformity is partially reducible passively. Weight-bearing X-rays show second MTP partial subluxation and hallux valgus angle of 30 degrees. What is your diagnosis and management?”
“A 62-year-old female with long-standing hallux valgus and crossover second toe presents after failed conservative treatment. On examination, the second toe is completely dislocated dorsally and medially over the hallux and is completely rigid - it will not reduce even with passive force. X-rays show complete MTP dislocation and early arthritis. How do you manage this?”
“A 58-year-old female presents with recurrent crossover toe deformity 18 months after soft tissue reconstruction (plantar plate repair, FDL transfer, Weil osteotomy). Her hallux valgus was NOT corrected at the initial surgery. The second toe has gradually drifted back into crossover position. What is the cause and how do you manage this?”
MCQ Practice Points
Q: What is the primary pathology in crossover toe deformity? A: Plantar plate tear at the second MTP joint. The tear (usually at insertion on proximal phalanx base) removes the plantar restraint, allowing dorsal subluxation driven by the extensor digitorum longus.
Q: What is the underlying cause in 80% of crossover toe cases? A: Hallux valgus (bunion deformity). The deviated great toe pushes the second toe dorsally and medially, overloading the plantar plate and causing it to tear.
Q: How do you differentiate Stage 2 from Stage 3 crossover toe? A: Reducibility: Stage 2 is semi-rigid (partially reducible with passive force). Stage 3 is completely rigid (irreducible even with passive force). This determines treatment - Stage 2 gets soft tissue reconstruction, Stage 3 gets arthrodesis.
Q: What are the five components of soft tissue reconstruction for Stage 2 crossover toe? A: (1) Weil osteotomy (shorten second metatarsal), (2) Plantar plate repair (suture anchors), (3) FDL transfer (flexor-to-extensor), (4) EDL lengthening, (5) Hallux valgus correction (bunionectomy).
Q: What is the most important factor to prevent recurrence of crossover toe after repair? A: Correct the hallux valgus concomitantly. Failure to address the underlying hallux valgus results in continued pressure on the second toe and inevitable recurrence.
Controversies and Areas of Uncertainty
| Question | Arguments | Current Position |
|---|---|---|
| Direct plantar plate repair vs flexor-to-extensor transfer | Direct repair restores native anatomy and toe purchase; flexor transfer is reliable but causes stiffness and may not restore purchase | Direct repair preferred for repairable (Grade II-III) tears; flexor transfer reserved for irreparable Grade IV (Nery/Coughlin protocol) |
| Dorsal vs plantar approach for plantar plate repair | Dorsal approach (with Weil osteotomy) gives joint access without plantar scar; plantar approach gives direct plate visualisation but risks painful plantar scar | Dorsal/Weil approach now most widely adopted; plantar approach less common due to scar morbidity |
| Role of routine MRI | MRI sensitive (87%) but poor specificity - tears seen in asymptomatic feet; clinical drawer sign is highly specific | Diagnosis is primarily clinical; MRI reserved for atypical presentations or pre-operative grading uncertainty |
| Weil osteotomy alone vs Weil plus plantar plate repair | Some shortening alone relieves pain; comparative data show added repair improves quality-of-life and pain scores | Repair the plate when a Weil is performed for instability (Fleischer 2020) |
| Optimal management of the predislocation (pre-deformity) stage | Early synovitis may respond to offloading and taping; injection risks plate rupture | Avoid intra-articular/peri-plate corticosteroid; early activity modification and orthoses, low threshold for surgery if instability progresses |
Guidelines, Registries & Global Practice
- Female predominance ~86%; peak in women over 50, mean age ~59 at surgery
- Strongly associated with hallux valgus and first MTP arthritis
- Higher prevalence in populations with high rates of constrictive/high-heeled footwear
- Inflammatory arthropathy (rheumatoid) a recognised cause worldwide, often multi-ray
- High-resource: MRI/ultrasound, suture-anchor plantar plate repair, dorsal Weil approach, day-case surgery
- Limited-resource: Clinical drawer-sign diagnosis, flexor-to-extensor transfer or resection arthroplasty (no implants required), buddy taping and footwear advice as first line
- Lesser-toe procedures are not tracked in implant joint registries (no prosthesis), so registry evidence is absent — evidence base is case series and small comparative studies
| Source | Position | Practical Implication |
|---|---|---|
| AOFAS / Foot & Ankle Int literature (Coughlin, Nery) | Anatomic tear-grade-directed treatment; combine with Weil shortening and correct hallux valgus | Internationally adopted operative algorithm |
| AO Foundation / EFAS (European Foot & Ankle Society) | Emphasise plantar plate as primary lesion; favour direct repair where reparable | Supports anatomic repair over indirect rebalancing alone |
| BOFAS (British Orthopaedic Foot & Ankle Society) practice | Clinical diagnosis with drawer test; staged conservative then surgical care | Reserve imaging for atypical cases |
| General consensus | No randomised trial defines a single best technique; treatment individualised to tear grade and rigidity | Counsel patients that evidence is largely Level III-IV |
For Orthopaedic fellowship examination, be prepared to discuss the five components of flexible (Stage 2) crossover toe repair (Weil osteotomy, plantar plate repair, FDL transfer, EDL lengthening, hallux valgus correction), explain why correcting the underlying hallux valgus is essential to prevent recurrence, and recognise that there is no single-society randomised guideline — management is grade- and rigidity-directed and based on case-series evidence.
DEFINITION
- Second toe crosses medially OVER hallux
- Primary pathology: plantar plate tear at 2nd MTP
- Underlying cause: hallux valgus (80%)
- Dorsal subluxation from loss of plantar restraint
- Progressive deformity: flexible to rigid
COUGHLIN STAGING
- Stage 1: Flexible, fully reducible - conservative
- Stage 2: Semi-rigid, partial reducible - soft tissue repair
- Stage 3: Rigid, irreducible - arthrodesis
- Flexibility determines surgical approach
- X-ray: subluxation (Stage 2) vs dislocation (Stage 3)
CLINICAL TESTS
- Paper pull-out test: cannot grip = plantar plate incompetence
- MTP Lachman: over 2mm dorsal translation = rupture
- Passive reducibility: determines stage
- Plantar ecchymosis: suggests acute tear
STAGE 2 SURGERY (5 COMPONENTS)
- 1. Weil osteotomy (shorten 2nd MT 3-5mm)
- 2. Plantar plate repair (suture anchors)
- 3. FDL transfer (flexor-to-extensor)
- 4. EDL lengthening (release contracture)
- 5. Hallux valgus correction (ESSENTIAL)
STAGE 3 SURGERY
- Arthrodesis (fusion) of 2nd MTP - gold standard
- Position: 15-20° plantar flexion, neutral alignment
- Fixation: plate/screws or K-wires
- Still need hallux valgus correction
- Resection arthroplasty = salvage (less stable)
KEY POINTS
- MUST correct hallux valgus or recurs (80% have HV)
- Good outcomes: Stage 2 (85%), Stage 3 (70%)
- Transfer metatarsalgia: excessive Weil shortening
- Recurrence 10-20%, mostly from uncorrected HV