What does it mean when the big toe has lateral creases?

Lateral Creases on the Big Toe: Clinical Significance

Lateral creases on the big toe most commonly indicate chronic pressure or friction from footwear, hallux valgus deformity, or congenital malalignment of the great toenail, all of which can lead to progressive nail dystrophy and soft tissue complications if left unaddressed.

Primary Causes and Mechanisms

Structural Foot Deformities

• Hallux valgus and hallux valgus interphalangeus are extremely common, occurring in over 90% of patients presenting with toenail pathology, and directly contribute to abnormal pressure distribution on the lateral aspect of the big toe 1
• The lateral deviation creates chronic friction against footwear, producing visible skin creases and predisposing to nail complications including compression nails, ingrown nails, and nail overcurvature 1
• Most toenail changes are directly associated with underlying foot and toe structural abnormalities, making isolated assessment of the toe insufficient 1

Congenital Malalignment

• Congenital malalignment of the big toenail involves lateral deviation of the nail plate due to matrix deviation, possibly from increased traction of the hypertrophic extensor hallucis longus tendon 2
• This condition is typically present at birth and commonly leads to ingrown toenails and onychogryphosis as complications 2
• The longitudinal axis shift of the nail creates visible lateral creasing of the surrounding soft tissue 2

Footwear-Related Pressure

• Inappropriate or ill-fitting footwear is a major cause of lateral toe pathology, even in patients with underlying vascular disease 3
• The shoe should be 1-2 cm longer than the foot, with internal width equal to the foot width at the metatarsophalangeal joints to prevent lateral compression 3
• Chronic pressure from tight footwear produces lateral creases, callus formation, and can progress to ulceration in high-risk patients 3

Clinical Assessment Algorithm

Examination Priorities

• Evaluate the entire foot in relaxed, standing, and walking positions to identify hallux valgus, hallux valgus interphalangeus, or other structural deformities 1
• Assess for associated nail changes including compression nail, pincer nail, nail overcurvature, or ingrown nail 1
• Examine footwear meticulously for proper fit, rough edges, uneven seams, or areas causing focal pressure 3
• Check for signs of neuropathy or vascular compromise in diabetic or high-risk patients, as lateral creases may precede ulceration 3

Risk Stratification

• Patients with diabetes, neuropathy, or peripheral arterial disease require immediate attention as lateral pressure points can rapidly progress to ulceration 3
• Adolescents and children with lateral toe creases should be evaluated for congenital malalignment or Sever disease 4
• Athletes in barefoot sports (e.g., Taekwondo) may develop lateral toe injuries from rapid pivoting movements 5

Management Approach

Conservative Management

• Footwear modification is the primary intervention: ensure proper fit with adequate toe box width and depth, avoiding tight or narrow shoes 3
• Use lubricating oils or creams for dry skin associated with chronic friction, but avoid application between toes 3
• For congenital malalignment, conservative treatment may suffice for mild deviations, though surgical correction is recommended for severe cases 2

When to Refer

• Refer for surgical evaluation if conservative footwear modifications fail after 6-8 weeks or if progressive nail dystrophy develops 4
• Immediate referral is warranted for diabetic patients with lateral creases showing signs of skin breakdown, hyperemia, or pre-ulcerative changes 3
• Congenital malalignment with recurrent ingrown nails or significant functional impairment requires surgical consultation 2

Common Pitfalls

• Failing to examine the entire foot and footwear leads to missed diagnosis of underlying hallux valgus or structural deformities 1
• Dismissing lateral creases as purely cosmetic in diabetic or neuropathic patients can result in delayed recognition of pre-ulcerative lesions 3
• Treating isolated nail pathology without addressing causative foot deformities results in recurrent problems 1
• Overlooking congenital malalignment in children, leading to progressive complications including chronic ingrown nails 2