Toes that gradually drift apart or appear more widely spaced than you remember can have a surprisingly long list of causes, from a swollen nerve between the metatarsal bones to inflammatory joint disease to something you were born with. Whether the change is painful or purely cosmetic, the underlying reason matters because each cause calls for a different response. Some of these causes are common enough that a podiatrist sees them weekly; others are rare findings that show up only on imaging.
Morton’s Neuroma and the Sullivan Sign
One of the most common reasons two neighboring toes drift apart is a Morton’s neuroma, a thickening of tissue around a nerve that runs between the metatarsal heads of the foot. It most often affects the space between the third and fourth toes, though it can appear between the second and third. As the tissue swells, it physically pushes the adjacent toes away from each other. This visible gapping of the toes, with the digits diverging on either side of the affected space, has a clinical name: the Sullivan sign. A doctor checking for a Morton’s neuroma will often look for this divergence as part of the physical exam, along with squeezing the forefoot to reproduce a clicking sensation or pain.
The discomfort typically feels like burning or tingling in the ball of the foot, sometimes radiating into the affected toes. It often worsens in tight shoes or during activities that put pressure on the forefoot. If you notice two toes fanning apart and also have that burning sensation, a Morton’s neuroma is high on the list of possibilities.1StatPearls. Morton Neuroma
Intermetatarsal Bursitis and Rheumatoid Arthritis
Inflammatory joint conditions can produce toe separation that looks almost identical to the Sullivan sign but stems from a different structure. In rheumatoid arthritis, the small bursae that cushion the spaces between metatarsal heads can become inflamed and swollen, a condition called intermetatarsal bursitis. As the bursa enlarges, it pushes the neighboring toes apart in the same way a neuroma does.
A reported case illustrates the pattern well: a woman with a long history of rheumatoid arthritis noticed her third and fourth toes gradually separating over several months, with pain and a splayfoot deformity developing in one foot. MRI showed prominent intermetatarsal bursitis between those metatarsal heads. After ultrasound-guided aspiration and a steroid injection into the bursa, the bursitis resolved and the toes returned to their normal alignment.2PubMed Central. Separating toes due to intermetatarsal bursitis in rheumatoid arthritis This is worth knowing because the treatment for bursitis differs from the treatment for a neuroma, even though the symptom of separated toes can look the same from the outside. If you have rheumatoid arthritis or another inflammatory condition and notice two toes pulling apart, bursitis is a leading suspect.
Ganglion Cysts Near the Toe Joints
A less well-known cause is a ganglion cyst forming near one of the small joints in the toes. These fluid-filled sacs can develop next to the interphalangeal joints (the hinge joints within each toe) and, depending on size, can push a toe sideways or create visible spacing between adjacent digits. A study examining toe ganglion cysts found that the vast majority formed near the interphalangeal joint rather than elsewhere along the toe. Cysts that were located right next to the joint had a frustrating tendency to recur after surgical removal, with about half requiring a second operation, while cysts farther from the joint healed more reliably after a single excision.3PubMed Central. Excision with Temporary Interphalangeal Joint Pin Fixation for Toe Ganglion Cysts
Ganglion cysts are typically firm, round, and sometimes visible or palpable on the top or side of a toe. They may or may not be painful. If you feel a distinct lump near a toe joint along with unusual spacing, a cyst is worth ruling out.
Sandal Gap and Congenital Toe Spacing
Sometimes the spacing between toes has been there since birth. The most recognized congenital variant is the “sandal gap deformity,” a wider-than-usual gap between the first and second toes. It gets its name from the space where a thong-style sandal strap sits. This gap has been identified on prenatal ultrasound as part of a broader set of focal musculoskeletal anomalies that can be detected before birth.4PubMed Central. Prenatal sonographic diagnosis of focal musculoskeletal anomalies
The sandal gap has historically been linked to Down syndrome (trisomy 21), where it appears more frequently than in the general population. When it shows up on a second-trimester ultrasound, it is sometimes flagged as a “soft marker,” meaning it raises the statistical probability of the condition but is far from diagnostic on its own. The evidence connecting an isolated sandal gap (with no other markers) to trisomy 21 on prenatal imaging is actually limited, and the finding is described as poorly characterized in the prenatal context.5Journal of Obstetrics, Gynecology and Cancer Research. Isolated Sandal Gap as a Soft Marker for Trisomy 21: A Case Report and Narrative Review of the Literature In many people, a wider gap between the first and second toes is simply a normal anatomical variant with no clinical significance at all.
If your toes have always been spaced this way and you have no pain, the odds are good that this is just the shape of your foot. If the gap appeared gradually in adulthood, that points to an acquired cause rather than something congenital.
Diabetic Neuropathy and Intrinsic Muscle Wasting
Diabetes can reshape the foot in ways that go far beyond the skin ulcers most people associate with the disease. The small intrinsic muscles of the foot, which help keep the toes aligned and stabilized during walking, are vulnerable to wasting when nerve supply deteriorates. What’s striking is that this muscle atrophy can begin even before standard clinical tests pick up signs of neuropathy. Imaging research has shown that small foot muscle wasting is already present in people with diabetes who do not yet have detectable peripheral neuropathy by conventional exams.6PubMed Central. Foot small muscle atrophy is present before the detection of clinical neuropathy
As neuropathy progresses from mild to severe, the decline in muscle bulk becomes more pronounced across multiple foot muscles, including those responsible for holding the toes in their proper positions. Ultrasound and MRI studies have confirmed significant reductions in the cross-sectional area and thickness of key muscles like the flexor digitorum brevis and the abductor hallucis as neuropathy severity increases.7Egyptian Journal of Radiology and Nuclear Medicine. Role of ultrasound in early diagnosis of intrinsic foot muscle atrophy in diabetic patients: a comparative study with magnetic resonance imaging When those muscles weaken, the balance of forces across the metatarsal heads shifts, and toes can splay, claw, or drift apart.
Strength testing backs this up. In studies comparing diabetic patients with neuropathy to healthy controls, the neuropathy group showed measurably lower strength in toe flexion tasks, with statistically significant differences across several measurements.8PubMed Central. Analysis of Intrinsic Foot Muscle Strength in Diabetic Patients With and Without Diabetic Peripheral Neuropathy Compared With Healthy Controls If you have diabetes and notice your toes gradually spreading or curling, weakened intrinsic foot muscles driven by nerve damage are a likely contributor, and it is worth raising with your care team sooner rather than later.
Hypermobility and Connective Tissue Disorders
People with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder often have foot mechanics that differ from the general population in ways that can affect toe alignment. Research comparing gait patterns in people with hypermobility to healthy controls found that the hypermobile group had a significantly more mobile first ray, with increased eversion of the medial forefoot during the stance phase of walking. They also showed more dorsiflexion in both the forefoot and rearfoot.9PubMed. Altered Multisegment Ankle and Foot Kinematics During Gait in Patients With Hypermobile Ehlers-Danlos Syndrome/Hypermobility Spectrum Disorder: A Case-Control Study
What this means in practical terms is that the ligaments and connective tissue that normally hold the bones of the forefoot in a compact arch are stretchier, allowing the metatarsal heads to spread further apart under load. Over time, this can translate to visible toe splaying, particularly between the big toe and the second toe. If your toes seem to spread out noticeably when you stand but come back together when you sit, and you’ve always been unusually flexible, hypermobility could be part of the picture.
Plantar Plate Tears and Joint Instability
The plantar plate is a thick, fibrous pad of tissue on the underside of each metatarsophalangeal joint (the joint where a toe meets the ball of the foot). It acts as a stabilizer, keeping the toe seated against the metatarsal head during push-off. When this structure tears, the affected toe loses its anchor and can drift upward, sideways, or away from its neighbor. Plantar plate tears most commonly affect the second toe and are a frequent precursor to crossover toe deformity, where the second toe gradually rides over the big toe.
In more advanced cases, the joint itself can partially or fully dislocate. Surgical correction for this kind of instability typically involves restoring the ligament support and sometimes shortening the metatarsal bone to reduce the forces on the joint.10PubMed. Plantar Pressure Distribution Before and After Surgery for Lesser Metatarsophalangeal Joint Dislocation With Hallux Valgus If one toe seems to be drifting away from its neighbors and you feel instability or a sense that the toe “gives” when you push off, a plantar plate problem is a possibility your doctor can evaluate with physical tests and, if needed, imaging.
Bunions and Their Ripple Effects
A bunion (hallux valgus) is one of the most visible causes of abnormal toe spacing, though people don’t always think of it in those terms. As the big toe angles inward toward the second toe, the first metatarsal bone shifts outward, widening the gap between the first and second metatarsal heads. This creates the characteristic bump on the inner side of the foot, but it also changes the spacing and alignment of the entire forefoot. The second toe, crowded by the encroaching big toe, may ride up, underlap, or drift laterally, and you can end up with wider gaps between the second and third toes as a downstream effect.
The research on weight-bearing CT imaging has deepened the understanding of what happens inside the foot during bunion formation. Unlike standard X-rays, weight-bearing CT reveals the true three-dimensional orientation of the bones under load, and studies using this technology have found that the first metatarsal actually rotates (pronates) in patients with bunions compared to those without, an insight that plain films can miss entirely.11PubMed. Weight-bearing CT Scans in Foot and Ankle Surgery This rotation contributes to further instability and splaying of the forefoot beyond what simple angulation would explain.
Exercises, Orthotics, and Conservative Treatment
What you do about separated toes depends entirely on what is causing them. For some causes, conservative treatment can make a real difference; for others, the goal is more about managing symptoms or preventing further progression.
Toe-strengthening exercises have solid support for improving foot function. A systematic review of intrinsic foot muscle strengthening programs found that these interventions improved strength, balance, and mobility in older adults, with some evidence suggesting reduced fall risk as well. The proposed mechanism is that stronger foot muscles enhance proprioception, your brain’s sense of where your foot is in space.12PubMed. The effects of intrinsic foot muscle strengthening on functional mobility in older adults: A systematic review Simple exercises like towel scrunches, marble pickups, and short-foot drills (where you try to shorten the arch of your foot without curling the toes) are commonly recommended and can be done at home.
Silicone toe spacers have become popular, both as standalone products and as add-ons to foot-strengthening programs. However, the evidence for spacers alone is modest. A randomized controlled trial comparing six weeks of foot-strengthening exercises with and without a silicone toe spacer found that both groups improved in hallux alignment and mobility, but adding the spacer did not provide additional short-term benefit beyond what exercise alone accomplished.13Applied Sciences. Effects of Foot Strengthening Exercises With or Without a Toe Spacer on Hallux Alignment, Foot Mobility, and Balance: A Randomized Controlled Trial Spacers can still feel good and may help with comfort, but the exercises themselves seem to be doing the heavy lifting.
For bunion-related spacing, a total contact insole with a built-in toe separator has shown more encouraging results. In patients with painful hallux valgus, this type of orthotic reduced the hallux valgus angle by an average of about 6.5 degrees, reduced pain, and improved walking ability.14PubMed. The effects of a new foot-toe orthosis in treating painful hallux valgus That won’t reverse a severe bunion, but for mild to moderate deformity it represents a meaningful non-surgical option.
When conservative approaches fall short, surgical options exist for many of the underlying conditions. Morton’s neuromas that don’t respond to injections and wider shoes can be excised. Plantar plate tears can be repaired arthroscopically or through open surgery. Bursitis from rheumatoid arthritis may respond to aspiration and corticosteroid injection, as described earlier, but recurrent cases can require surgical removal of the bursa. Bunion correction surgery addresses the metatarsal alignment directly. The key is getting the right diagnosis first, because a toe spacer and some exercises won’t help a ganglion cyst, and a steroid injection won’t address a congenital sandal gap.
When to See a Doctor and What They Might Order
Toe separation that comes on gradually and without pain is less urgent but still worth mentioning at your next appointment, especially if you have diabetes or an inflammatory condition. Separation that appears relatively quickly over weeks to months, or that comes with pain, burning, numbness, or a visible lump, warrants a dedicated visit.
Your doctor will likely start with a physical exam, checking for tenderness, clicking sensations when the forefoot is squeezed (the Mulder click associated with neuromas), joint stability, and visible deformity. If the clinical picture isn’t clear, imaging comes next. Standard X-rays catch bone alignment problems and obvious joint damage. Ultrasound is useful for soft tissue masses like neuromas and ganglion cysts and can be done in the office. MRI provides the most detailed view of both bone and soft tissue and is particularly helpful for plantar plate tears, bursitis, and early muscle atrophy.
Weight-bearing CT is a newer tool that is gaining ground in foot and ankle practice. Because it captures the bones in their loaded, functional position, it reveals alignment problems that regular CT or X-rays can miss. Researchers have used weight-bearing CT to discover rotational components of bunion deformity and to better characterize instability in the ankle and forefoot.11PubMed. Weight-bearing CT Scans in Foot and Ankle Surgery Not every clinic has one yet, but if your surgeon is planning a procedure, it may be part of the workup.
The practical takeaway is that separated toes are a symptom, not a diagnosis. The spacing itself is rarely dangerous, but the condition driving it sometimes is, particularly when neuropathy, inflammatory arthritis, or progressive joint instability is involved. Figuring out which cause applies to you is the step that unlocks the right treatment.