Congenital Malalignment of the Great Toenails

By Emily White|2025-02-25T07:42:18+00:00September 25th, 2022|

What is CMGTN?

Congenital malalignment of the great toenails (CMGTN) is a condition affecting the growth of the big toenails, causing one or both to deviate from their normal longitudinal axis and grow in a lateral direction. If severe or not managed appropriately, it can lead to complications resulting in a deformed nail that periodically sheds itself, is thickened, discoloured and in some cases painful.

Why does CMGTN happen?

It is believed that the malalignment of the great toenails is present at birth, with genes playing a major causal role. It has also been suggested that a tightening of the extensor tendon in the toe can pull on the nail matrix leading to a lateral rotation and consequent deviation of the nail plate. Other suggested factors include constriction of the toes by amniotic bands and increased pressure or vascular abnormalities while in utero. More recently, it has been hypothesised that a desynchronisation in growth between the nail and the distal phalanx of the great toe results in a larger nail plate that is forced to deviate out of alignment due to constrictions within the nail bed.

Many cases will be picked up in early infancy, however in milder cases it is not until extrinsic factors come into play that symptoms become more obvious. This can result in a diagnosis made later in childhood. Extrinsic factors include those that cause repeated microtrauma to the nail anatomy. These can include crawling and gait anomalies, onesies with enclosed feet that are too tight or ill-fitting footwear.

Signs of CMGTN

Signs of CMGTN in newborns and infants include:

One or both of the big toenails growing on an angle in a lateral direction
Thickening of the affected nail
Inflammation, including redness, swelling and pain next to the lateral aspect of the nail
Hypertrophy or enlargement of the lateral nail folds

How is CMGTN diagnosed?

CMGTN can be diagnosed by one of our experienced Melbourne Podiatrists who will:

Take a thorough patient and familial history
Conduct an examination of the nails’ appearance and surrounding tissue
Assess and consider possible extrinsic factors that may be causing microtrauma to the nail anatomy
Conduct a biomechanical assessment and gait analysis to determine if mechanical external factors are at play

The podiatrists at our Melbourne clinic are experienced at distinguishing between different conditions and ruling out differential diagnoses. An accurate diagnosis is essential in order to treat the condition appropriately, avoid unnecessary and unhelpful treatments that may be time consuming and costly and to minimise life-long nail complications.

How can our Melbourne Podiatrists help with CMGTN treatment?

Our Melbourne podiatrists are skilled in treating dermatological and nail conditions in patients of all ages including infants and children with CMGTN. Close and regular monitoring of the affected nails over time, often using photographs taken periodically, will enable our Melbourne podiatrists to provide an individualised and tailored treatment. The type of treatment will depend on how early the diagnosis is made, the age of the individual, as well as the severity of the malalignment and the complications caused.

Treatment of CMGTN may also involve reduction of nail bulk to allow the nail plate to better fit within the nail bed space. In more longstanding cases, whereby periodic nail shedding is occurring, special taping techniques can assist in improving the alignment of the nail plate.

Although we cannot resolve genetic predispositions to congenital malalignment of the great toenails, our skilled Melbourne podiatrists will assist you to address external factors to reduce repetitive microtrauma to the nails. This may involve footwear education as well as addressing gait and biomechanical factors with orthotics to minimise ongoing nail trauma. Although complete resolution of congenital malalignment of the great toenails is not always possible, early intervention with a podiatrist is key.