Overlapping and Underlapping Toes: Causes, Conservative Care, and Surgery

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

What Causes Toes to Overlap or Underlap?

Overlapping toes — where one toe crosses over an adjacent toe — and underlapping toes — where a toe curls under a neighboring toe — are both lesser toe deformities resulting from muscle imbalance, structural factors, and progressive deformity of the metatarsophalangeal (MTP) joints. The second toe overlapping the great toe is among the most common patterns, often driven by a bunion deformity that pushes the great toe toward the second, causing the second to displace dorsally (upward) and ultimately cross over the great toe.

Congenital overlapping of the fifth toe is a distinct condition present from birth, in which the fifth toe overlaps the fourth. This variant often becomes symptomatic only in adulthood when shoe wear creates painful pressure. Underlapping of the fourth and fifth toes can be congenital or acquired. Lesser toe deformities frequently coexist with hammertoes, bunions, and plantar plate tears.

Symptoms and Why They Worsen Over Time

Overlapping toes create concentrated pressure wherever the displaced toe contacts the shoe — typically on the dorsal (top) surface of the displaced toe and on the adjacent toe being pressed against. Painful corns form at these pressure points. Calluses develop on the sole where altered weight distribution concentrates pressure. Skin breakdown can occur in patients with poor circulation or neuropathy. Shoewear becomes difficult and painful as the deformity progresses. Without intervention, the joints stiffen into increasingly rigid positions, narrowing treatment options.

Conservative Management

Conservative care focuses on accommodating the deformity and protecting pressure points. Wider, deeper-toed shoes allow the crossing toes to be positioned more comfortably. Toe separators (silicone spacers placed between adjacent toes) keep toes in better alignment and protect the web spaces from friction. Toe sleeves provide padding over corn-prone areas. Buddy-taping (taping the deviated toe to an adjacent toe) provides temporary alignment correction. For congenital fifth toe overlap that causes primarily shoe pressure, conservative measures are often the definitive long-term management.

Surgical Correction of Overlapping Toes

When conservative measures are inadequate, surgical correction provides definitive alignment. For flexible overlapping toes (still passively correctable), soft tissue procedures — releasing contracted tendons and capsular structures, rerouting a flexor tendon — restore balance without bone surgery. Rigid deformities require bony correction: resection arthroplasty of the PIP joint (as in hammertoe surgery), or metatarsophalangeal joint capsulotomy with tendon releases. Congenital fifth toe overlap is corrected with a Butler procedure — a Y-to-V skin plasty combined with dorsal capsulotomy — typically as an outpatient procedure. The surgical approach is individualized to the specific anatomy and severity of each patient’s deformity.

Recovery and Results

Recovery from lesser toe surgery depends on the procedure performed. Soft tissue releases allow early protected weight-bearing within days. Bony procedures require 4–6 weeks in a surgical shoe followed by graduated return to standard footwear. Swelling and stiffness can persist for 3–6 months postoperatively. Long-term results are generally excellent for carefully selected patients who undergo appropriate procedures — the majority achieve better toe alignment, reduced pressure, and improved shoe comfort. Schedule a consultation at Balance Foot & Ankle at (810) 206-1402 to discuss your toe deformity treatment options.

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Overlapping or Underlapping Toes Causing Problems?

Overlapping and underlapping toes can cause pain, calluses, difficulty wearing shoes, and progressive deformity. Whether congenital or acquired from hammertoes and bunions, a podiatrist can provide conservative management or surgical correction for lasting comfort.

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Clinical References

1. Coughlin MJ. Lesser-toe abnormalities. Journal of Bone and Joint Surgery. 2002;84(8):1446-1469.
2. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot and Ankle. 1993;14(7):385-388.
3. Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. Journal of Bone and Joint Surgery. 1989;71(1):45-49.

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Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.