Morton's Toe

The majority of people with Morton’s toe have no symptoms. The few patients who do have symptoms present with:

• Calluses under the second or third head of the metatarsal.
• Vague discomfort of the fore foot while wearing constrictive shoes.
• Pain which can be sharp or dull. In some cases the pain may be felt under the arch or even more proximal towards the heel and ankle.
• People who wear tight shoes may also present with curved and ingrown toe nails.

The diagnosis of Morton’s toe can be suspected on a physical exam where the first metatarsal may appear to be much shorter than the second metatarsal. However, to confirm the diagnosis a plain X-ray of the foot is required. Usually no other imaging studies are needed. In rare cases, a CT scan may be performed in severely symptomatic patients to ensure that there is no other underlying pathology of the foot pain [7].

When a patient presents with pain in the forefoot, it is important to consider other more well-known causes such as:

• Morton neuroma
• Metatarsalgia
• Plantar fasciitis
• Callus
• Bunion
• Hammer toe
• Arthritis
• Scoliosis
• Kyphosis
• Sciatica

For asymptomatic patients, no treatment is required, but proper shoes can be recommended. For symptomatic patients, selection of proper shoe wear is essential. In general shoes with a wide and high toe box are recommended. Experts suggest that buying shoes a half size bigger to accommodate the longer second toe may be ideal. Further to support the arch, orthotic appliances can help keep the foot aligned. For those who develop calluses, a metatarsal pad can help relieve the stress on the head of the joints. For people who do not like to wear wide shoes, one may wear sandals. The majority of patients see relief from pain with these supportive measures. Surgery is almost never required for Morton's toe. If surgery is offered, a second opinion should be considered from an independent surgeon.

The prognosis for most patients with Morton's toe is excellent. Once the individual starts to use orthotic appliances or wear the right type of shoes, the pain disappears. However, a lifelong commitment to proper shoes is required to prevent he pain from recurring.

The cause of Morton's toe is unknown but most experts believe that it is hereditary. The genetic transmission is not complete and not everyone in the family develops Morton's toe. Factors that can exacerbate the symptoms include prolonged standing and walking and wearing tight constrictive shoes.

Even though Morton’s toe is often described in the orthopedic literature as a foot disorder, there are some who believe that it may just be a normal variant of the shape of the foot. For this reason its prevalence is quite variable in the literature. Most foot surgeons believe it to be a common presentation, albeit, without any symptoms. Outpatient clinic data indicate that Morton’s toe occurs in about 10% of the adult population, but in people who seek help for forefoot pain, the disorder is seen in about 80% of the individuals.

Morton’s toe can occur in both genders and in all races. However, because the deformity is asymptomatic, most people never come to medical attention and thus, the exact number of people affected remains unknown. Affected individuals usually present with symptoms in the second or third decade of life.

Because the second metatarsal is long, it places the joint base of the 2nd toe further forward, and thus, the horizontal plane along the metatarsal joints is uneven. The shortened first metatarsal and elongated second metatarsal cause to unevenness in the joint and laxity. This leads to transference of pressure on the head of the second and third metatarsal, leading to callus formation. There is also evidence that excess pronation of the foot due to the abnormal joint can lead to forefoot pain. This primarily occurs because during walking because the longitudinal arch of the foot sinks and the ankle turns inwards. The pronation leads to both functional and postural problems which causes the leg to be functionally lengthened or shortened and the extremity will internally rotate.

If severe, this can lead to an anatomically shortened leg, which leads to sagging of the pelvis on that side. Over time this can lead to mild to moderate scoliosis or kyphosis. The abnormal posture of the lower spine creates torque forces caused by the internal rotation of the leg, resulting in pain in various joints of the extremity. However, postural and functional changes are only seen in a few rare severe cases and even when this occurs, the cause is not always solely Morton's toe but other musculoskeletal disorders [5] [6].

It is not possible to prevent Morton’s toe as the cause is not known. However, once the diagnosis is made, patients should adhere to use of orthotic appliance and proper shoe wear to prevent symptoms.

Morton’s toe is a foot disorder also known as Greek foot, Morton’s foot or the Royal toe. The distinct feature about this condition is that the first metatarsal located behind the big toe is much shorter compared to the second metatarsal. The longer second metatarsal places the joint at the base of the second toe. Because of the abnormal anatomy, the first metatarsal can be hypermobile and have variable laxity.

Morton’s toe causes excessive pressure from weight bearing on the second metatarsal head, which results in discomfort that is similar to the pain encountered with metatarsalgia. The constant unrelenting pressure on the head of the 2nd and 3rd metatarsal heads while standing or ambulating, leads to callus formation. The condition is often mistaken for Morton’s neuroma, which is a syndrome associated with pain caused by a neuroma between the third and fourth heads of the metatarsals [1] [2] [3] [4].

Morton’s toe is a disorder of the foot, where one of the bones of the big toe is much shorter than that of the second toe. Thus, the first toe length not only appears shorter but the entire joint of the rest of the forefoot appears misaligned. Most people have no symptoms but a few people may have an odd pain in the foot and others may develop calluses. This pain is often worsened by wearing tight shoes. The diagnosis can be confirmed with an X-ray of the foot. The treatment of Morton’s toe is usually non-surgical with the use of orthotic appliances and better shoes. The condition unfortunately cannot be reversed or cured and hence, lifelong use of orthotic devices is required. Morton’s toe is a benign condition and symptoms usually subside once treatment is undertaken.

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