The sudden gapping or splaying between two adjacent toes, most often the second and third, is known as the “V” sign. This visible separation indicates a mechanical issue in the forefoot, often resulting from abnormal pressure or swelling between the long bones of the foot, called metatarsals. The symptom commonly points toward underlying conditions that cause nerve compression or structural instability in the ball of the foot. Understanding the origin of this mechanical stress is the first step toward finding relief and preventing the progression of the separation.
What Morton’s Neuroma Is
Morton’s Neuroma is a leading cause associated with the separation of the second and third toes. This condition is not a cancerous tumor but a thickening or enlargement of the tissue surrounding a common digital nerve in the forefoot. The thickening develops due to chronic irritation and compression of the nerve as it passes between the heads of the metatarsal bones, typically in the second or third web space.
The swollen nerve tissue creates an increased mass that physically occupies the confined space between the metatarsals. This mass acts like a wedge, pushing the two adjacent metatarsal heads apart and causing the toes to splay. Symptoms include sharp, burning pain, tingling, and numbness that radiates into the toes. Many people describe the feeling of standing on a small stone under the ball of the foot, which is the sensation of the compressed nerve during weight-bearing activities.
Other Structural and Inflammatory Causes
Toe separation can also stem from problems related to the structural integrity and stability of the forefoot, independent of nerve thickening. A Plantar Plate tear is a common structural injury where the strong ligament beneath the metatarsophalangeal joint is damaged. A tear can cause the affected toe, often the second, to lift up and separate from its neighbor, creating a distinct “V” shape.
Interdigital Bursitis, an inflammatory condition, involves the swelling of a fluid-filled sac located between the metatarsal bones. When inflamed, the bursa enlarges and can physically push the metatarsals apart, similar to a neuroma. Furthermore, Splayfoot involves the flattening of the transverse arch across the ball of the foot, causing the metatarsal bones to spread out. This widening of the forefoot results in the separation of the toes and increases pressure on surrounding structures.
How Footwear and Gait Influence Separation
External factors such as footwear choices significantly contribute to the development of forefoot conditions that lead to toe separation. Shoes that are too narrow or have a pointed toe box force the metatarsal bones together, increasing compression on the nerves and bursae. This squeezing action initiates or exacerbates the thickening of a neuroma or the inflammation of a bursa. High-heeled shoes also place excessive pressure directly onto the ball of the foot, increasing the load on forefoot structures. This mechanical overload can strain the plantar plate ligament and contribute to its tearing.
An abnormal walking pattern, such as overpronation—where the foot rolls inward excessively—also impacts forefoot mechanics. Overpronation can lead to increased stress on the second metatarsal, promoting arch collapse, splayfoot, and subsequent toe separation.
Diagnosis and Management Options
If you notice a persistent separation or experience pain in the ball of your foot, consulting a podiatrist or orthopedic specialist is the recommended next step. The diagnostic process typically begins with a thorough physical examination, including specific maneuvers to reproduce the pain and check for joint instability. Imaging studies are often used to confirm the diagnosis and rule out other issues, such as a stress fracture or arthritis. X-rays assess bone structure, while an ultrasound or MRI is necessary to visualize soft tissue pathology, such as a neuroma, bursitis, or a plantar plate tear.
Initial management focuses on non-surgical, conservative treatments aimed at reducing pressure and inflammation.
Conservative treatments include:
- Switching to footwear with a wider toe box and a lower heel to decompress the forefoot.
- Using custom orthotics or specialized metatarsal pads to support the collapsed arch and redistribute pressure.
- Taking anti-inflammatory medications to manage pain and swelling.
- Receiving a corticosteroid injection directly into the interspace to reduce nerve or bursa inflammation.
For cases that do not respond to conservative care, surgical options exist, which may involve nerve decompression or the surgical removal of the neuroma, known as a neurectomy.