What does the too many toes sign mean? I took my son to see the orthopedic surgeon for a chronic problem with ankle pain. When he was showing us what’s wrong, he used this term. But I don’t really know what it means.

The too many toes sign refers to a position of the foot that allows the examiner to see all four toes when looking at the foot from behind. With a normal, neutral alignment of the ankle, only the baby (or fifth) toe is usually seen.

Too many toes is a sign that the arch of the foot is dropped down toward the floor. The forefoot is moved away from the big toe. This position is called forefoot abduction. Abduction means away from the midline.

At the same time, the hindfoot (where the Achilles’ tendon inserts along the heel bone) angles inward toward the other foot. This is called hindfoot valgus. This position makes it difficult for the person to lift the heel off the floor and rise up on the toes.

The cause of this change in normal alignment of the foot and ankle is usually damage to the soft tissue from an ankle sprain that hasn’t healed properly.

If one tendon pulls strongly but is unopposed by a weak or injured tendon, then the nearby ligaments are over stretched. The arch drops and over time these other changes take place.