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Plantar Plate Injury (Dysfunction)

What Is A Plantar Plate Injury?

As the name suggests it is when there is an injury and damage to the plantar plate.

The plantar plate and plantar fascia resist upward (dorsal) displacement of the toe. The plantar plate is a fibrocartilaginous thickening of the plantar capsule of the MTP joint. This is continuous with the periosteum (surface layer on bone) of the base of the proximal phalanx. It is attached to the metatarsal head by the collateral ligament.

An illustation of the plantar plate

The plantar plate

Read more about the plantar plate under lesser toe anatomy and ligaments of the foot and ankle in Foot and Ankle Anatomy.

MRI of the foot showing a tear in the plantar plate and capsule

MRI of the foot – injected dye into the MTP joint is shown to leak outside the joint indicating tear in the plantar plate and capsule

What Can Cause It?

The following conditions may cause plantar plate injuries:

Please read 2nd MTP joint instability and crossover toe for related information.

What Are The Symptoms?

Pain is by far the commonest symptom. Pain may be felt in the “ball” of the 2nd toe joint, on the plantar (sole) aspect of the foot. Pain may also be felt across the dorsum (top) of the foot at the 2nd MTP joint. The pain is typically of gradual onset and has been present for over 6 months at presentation to an orthopaedic foot and ankle specialist.

Swelling may be present particularly as the condition progresses, and there may be increased warmth in the joint.

Deformity can occur as the condition progresses. The 2nd toe elevates initially, a hammer toe deformity (flexion at the PIP joint and extension at the MTP joint) frequently occurs and finally the toe crosses over.

Examination initially may reveal nothing but tenderness across the 2nd MTP joint. As the condition progresses swelling can occur, and the 2nd toe starts to drift (medially) towards the big toe. Later the 2nd toe crosses over or under the big toe. Thickening of the skin (callosity) under the 2nd MTP joint is typically a manifestation of increased load and forces going through the joint. The callosity may be painful and attempts to remove it will be temporary as the skin will thicken again in response to the abnormal load.

Your surgeon Mr Malik will look for the following on clinical examination:

  • Tenderness at the metatarsal head
  • Instability of the toe (positive drawer test)
  • Pain and abnormality at the big toe (1st MTP) joint
  • Other lesser toe deformities
  • Presence of Hammer toe
  • Presence of Crossover toe
  • Other areas of tenderness and pain
  • Signs and symptoms of a Morton’s neuroma
  • Evidence of calf tightness and forefoot overload
  • Presence of callosities

What Investigations May Be Required?

Radiographs will be arranged at your initial clinic consultation. These will help confirm the diagnosis, the severity of the deformity and aid in pre operative planning.


Radiographs

Radiographs (x-rays) are a useful first line investigation to rule out any other problems in the forefoot. They may be normal in the early stages of the condition. The 2nd MTP joint may appear distended.  In later stages of the condition there is dorsal and medial subluxation of the toe.

Radiograph showing mild medial deviation of the 2nd toe

Radiograph of left foot demonstrating 2nd MTP joint instability


Ultrasound

Ultrasound is used to confirm swelling (synovitis) in the 2nd MTP joint, and to see if there is anything else that may be causing the symptoms for example, Morton’s neuroma or intermetatarsal bursitis.


MRI

MRI is one of the most sensitive imaging techniques for plantar plate injury. It provides excellent high definition static images.

MRI is particularly useful in assessing:

  • Cartilage damage
  • Reactive bone changes (stress response)
  • Synovitis (inflammation and fluid in the joint)
  • Damage to the plantar plate
  • Other pathology
An MRI of the foot demonstrating inflammation (synovitis) in the 2nd MTP joint

An MRI of the foot demonstrating inflammation (synovitis) in the 2nd MTP joint

An MRI in combination with a small injection into the joint can help confirm any injury to the plantar plate (if there is a tear, fluid leaks out of the 2nd MTP joint, see image below), it can also confirm any stress lesions in the bone itself. If the underlying diagnosis is not clear an MRI can be a useful investigation.

MRI of the foot demonstrating leaking out of dye injected into the 2nd MTP joint indicating that there is a likely tear in the plantar plate and capsule

MRI of the foot demonstrating leaking out of dye injected into the 2nd MTP joint indicating that there is a likely tear in the plantar plate and capsule

Can The Problem Get Worse?

The natural history of this condition is not clearly understood.

It could be that many people with plantar plate injuries get better with time and rest and never report their symptoms to a doctor. As orthopaedic foot and ankle surgeons we are seeing more of this condition but that is probably due to increased awareness and understanding of this problem rather than a true increase in incidence of the condition.

Left untreated and despite conservative treatment plantar plate injury can progress and cause increasing pain and deformity in the foot.

The following are radiographs taken over 3 years with a patient with 2nd MTP joint instability with a plantar plate injury:

A radiograph showing a normal 2nd MTP joint

A radiograph showing a normal 2nd MTP joint

x-ray showing mild medial deviation of the 2nd toe

X-ray showing mild medial deviation of the 2nd toe

Subluxation at the 2nd MTP joint

Subluxation at the 2nd MTP joint

MRI showing dislocation at the 2nd MTP joint with attenuation of the plantar plate

MRI showing dislocation at the 2nd MTP joint with attenuation of the plantar plate

An x-ray showing surgical correction of the plantar plate

The patient eventually underwent surgical correction with a plantar plate repair and had a good result in terms of deformity correction, restoration of normal anatomy and pain relief

Non-Operative Treatment Options

Non-operative management aims at relieving pain and possibly preventing disease progression. It is likely to be most effective in the early stage of plantar plate injury.

It should always be the first line of treatment. Options include:

Activity modification

A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports that involve lots of turning, twisting and bending of the toes such as running, dancing, basket ball etc.


Ice

In the acute stage, RIE (rest, ice, and elevation) may help alleviate the pain.


Toe sleeves

Made of silicon can be worn over the toe to protect from direct pressure and rubbing against footwear.


Taping/strapping

Position the toe in neutral alignment using cross over taping or toe straps. Provide stability to the joint and alleviate symptoms. If there is no deformity then taping may allow healing to occur. If deformity is present, then prolonged taping will not correct this.

An example of taping which has failed to correct the deformity

An example of taping which has failed to correct the deformity


Insoles & orthotics

An insole with a metatarsal dome pad just proximal to the 2nd MTP joint can take some of the pressure off the joint and alleviate the pain. Stiffening the area under the 2nd metatarsal head with an orthoses can reduce the forces across the 2nd MTP joint. A rocker bottom sole may also help relieve dorsiflexion of the toe, which again would reduce the forces across the 2nd MTP joint. An insole that has a recess for a callosity may also reduce pain.


Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from an inflamed synovitic 2nd MTP joint.


Footwear Modification

The use of stiff soled shoes that do not bend and therefore protect the 2nd MTP joint.


Physiotherapy

Stretching tight calf muscles will help reduce the forces going across the forefoot. This will help reduce pain in the 2nd MTP joint.

Operative Treatment Options

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. In general, mild deformities can be treated by soft tissue procedures; severe deformities may require the addition of a bony corrective surgery (resetting the bone).

Please see 2nd MTP joint instability, crossover toe and hammer toe for related details of operative treatment options. Below we will discuss only the surgical procedure for plantar plate repair.


Plantar Plate Repair

The procedure is carried under general anaesthesia. The operation will take roughly an hour. It will almost always be a daycase procedure which means you can go home the same day.

An incision is made over the top of the foot at the level of the 2nd MTP joint (most commonly involved joint). The 2nd metatarsal is shortened and the torn plantar plate identified. It is then reattached to the base of the 2nd toe.

Illustration of the key steps during a plantar plate repair operation

Illustration of the key steps during a plantar plate repair operation

 


 

At the time of surgery any other toe deformity such as a hammer toe and bunion will also be corrected.

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment include:

  • Worsening pain
  • Increasing deformity
  • Dislocation of 2nd toe
  • Crossover toe deformity
  • Formation of ulcers on the sole of the foot (plantar aspect of 2nd MTP joint)
  • Formation of ulcers across the top (dorsum) of the second toe as it rubs against the shoe
  • Failure of taping
  • Infection of ulcers
  • Transfer metatarsalgia
A - Clinical picture of crossover toe with corresponding B - x-ray of the foot, note severe hallux valgus deformity and dislocation at the 2nd MTP joint

A – Clinical picture of crossover toe with corresponding B – x-ray of the foot, note severe Bunion (hallux valgus) deformity and dislocation at the 2nd MTP joint

This patient had an ulcer form at the site of their callosity which subsequently became infected

This patient had an ulcer form at the site of their callosity which subsequently became infected


Complications can occur as with any type of surgery. Please see foot and ankle complications for more detailed explanation of post surgical complications.

Potential complications of operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • In the case of an MIS procedure it may be necessary to proceed to open surgery if during the operation it is felt that a better outcome will be achieved using an open technique
  • Failure to fully correct deformity (particularly if longstanding deformity)
  • Recurrence of the deformity
  • Stiffness of the 2nd MTP joint
  • Wound healing problems (particularly when correcting a chronic dislocation the soft tissue can become contracted)
  • In chronic deformity the blood vessels contract, straightening the toe stretches these vessels potentially compromising the blood supply
  • Complex regional pain syndrome
  • Need for further surgery

Note – this list is not exhaustive and is meant as a guide.

Post Operative Period & Recovery

Immediate post operative period

Almost all surgical procedures for plantar plate injury will be undertaken as a day case.

You will have a bandage applied similar to this during the operation.

IMG_3017

Post operative bandage of the foot

Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.

Post operative stiff soled shoe

Post operative stiff soled shoe

For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.

IMG_8056

High elevation of the foot and ankle

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped in a toe splint.

IMG_2993

An example of taping of the foot to help maintain the surgical correction and allow the structures to heal in the correct position

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.

Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 weeks before any driving is advisable.

Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.

Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.


Six weeks post operatively

You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 weeks to heal.

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.

You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.


Three months post operatively

Final clinical examination. Discharge if satisfactory.

FAQs

When can I wear normal shoes?

This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a stiff soled shoe with a wide toe box while your foot continues to heal.

When can I drive?

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.

When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.

What should the final outcome be?

Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.

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