Plantar Plate Injury: causes, symptoms and treatment options

Updated 2/3/2019
Dr. Baravarian discusses plantar plate injuries, their causes, the symptoms and the treatment options at University Foot and Ankle Institute.

What's the Plantar Plate?

The plantar plate is a strong ligament on the bottom of the foot, a fiberous structure that starts at metatarsal head and attaches to the proximal phalanx through the joint capsule within the forefoot.

 

It's job is to keeps the toes in place and stops them from over-extending or drifting. So it stabilizes the metatarsophalangeal joints (MTPJ) and is also is an attachment site for the plantar fascia. 

 

Over the years many names have been used for plantar plate injuries and plantar plate tears including hammertoe, crossover toe deformity, metatarsophalangeal joint instability (also known as MPJ instability), metatarsalgia, predislocation syndrome and more.

What Causes Plantar Plate Tears?

The main cause is usually abnormally high amount of pressure on the associated metatarsophalangeal joint (MPJ region). This causes strain and eventually tears the plantar plate region. That results in the instability and pain in the joint that most patients report.

 

Although plantar plate tears can occur suddenly, they most often develop slowly over time from a progressive degeneration of the ligament from repetitive overuse or abnormalities including:

 

  • Biomechanical abnormalities include a short or elevated 1st metatarsal, or a long second metatarsal. These put constant pressure on the plantar plate and contribute to its degeneration.
  • Bunions (hallux valgus) can also put increased pressure on the plantar plate. Large bunions that push on the 2nd toe can eventually under-lap the toe, causing it to dislocate. This dislocation is caused by of thinning and stretching of the plantar plate as a result of the pressure from the bunion.
  • Cortisone injections can occasionally cause weakening and thinning of the plantar plate ligament. Patients who have steroid injections to help relieve pain in the ball of the foot may have noticed increasing deviation of the affected toe after the injection

 

Plantar Plate Injury Symptoms 

Plantar Plate Repair Surgery, Plantar Plate Treament

Plantar plate injury with medial toe deviation and surgeon’s incision placement.

 

Pain and Swelling

Pain can be described as a dull ache or a sharp pain in the ball of the foot and it may feel as though there is not enough cushion between the bone and the ground

 

Shifting of the toe

Over time, as the tear increases, the toe (most commonly the 2nd or 3rd toe) will begin to shift upwards or to one side, especially the 2nd toe moving towards the great toe. When the foot is placed on the ground the toe may not touch. When the toe is elevated in this way, more pressure is placed onto the head of the metatarsal, causing bone bruising and pain.

 

Chronic Plantar Plate Injury

If the plantar plate tear is not treated properly, the condition becomes chronic and the deformity can be greater. As the deformity progresses, the cartilage in the joint capsule can become eroded, leading to arthritis and increased pain. Further damage to the plantar plate and may cause the toe to dislocate out of joint resulting in a more difficult surgical correction.

 

 

Diagnosing a Plantar Plate Tear

Clinical Examination

Your doctor will move and manipulate the troubled toe joint into several different positions to evaluate the amount of deformity and the location of the pain. Often there's inflammation and pain at the plantar aspect of the sulcus distal to the metatarsal head and pain at the base of the proximal phalanx. There is a way to test the integrity of the ligament, called the “Lachman’s test” or the “drawer test,” but it is no longer considered reliable.


X-rays (radiographs)

These show the degree and angles of the toe deformity, as well as any arthritis in the joint. Weight bearing x-rays are the first thing needed to assess plantar plate injuries. In some cases, a special radiographic x-ray with a dye is injected into the joint to find the tear in the ligament.


Additional Imaging

Though x-rays are very helpful, magnetic resonance imaging (MRI) can directly show us the quality of the plantar plate, something x-rays simply cannot do. The MRI will show the plantar plate ligament and if it has any joint effusion, thickening and partial to complete plantar plate ruptures. We also may use ultrasound as well.

 

 

UFAI patient Kathy discusses her plantar plate repair surgery and how it significantly improved her quality of life.

Conservative Treatments for a Plantar Plate Injuries

 

    In the early stages of the plantar plate injury, conservative treatments can be successful. The first step is to identify and stop the activity that is causing the injury. 

     

    Treatment initially consists of icing, NSAIDs, relative rest, plantarflexion strapping of the digit and accommodative padding to reduce loads under the affected metatarsophalangeal joint. 

     

    In acute cases, your doctor may prescribe a boot to take weight off the ball of the foot. Tape may be wrapped around the toe to hold it in a downward position for several weeks. If there is any deformity from side to side, the tape can hold the toe in the opposite direction. This allows the ligament to heal without continued strain.

     

    Custom molded orthotics may also be prescribed. Orthotics with support under the ball of the foot alleviates pressure off the overstretched area and keeps the deformity from returning. Anti-inflammatories may be recommended to reduce pain and inflammation.

     

    But if the toe has drifted significantly, this indicates that the ligaments around the toes have been stretched. In those cases conservative treatments may ease the pain, but surgical treatments are necessary get the toe back into correct position.

     

     

    Plantar Plate Repair Surgery and Repair Techniques


    The HAT-TRICK Procedure

    Our surgeons worked directly with manufactures and scientists in the design of a product that has revolutionized plantar plate repair, called the HAT-TRICK.

     

    Dr Baravarian explains the HAT-TRICK technique that has revolutionized plantar plate repair surgery.

    Because plantar plate repair surgery rarely requires operating only on the plantar plate, the HAT-TRICK takes an innovative approach to the three distinct portions of the surgery. The result is a significant increase in success rates.

     

    The HAT-TRICK device not only allows for effective repair of the plantar plate and realignment of the toe, but also allows for collateral ligament repair. In many cases of plantar plate tear, the collateral ligaments on the sides of the toes have torn as an adjunct to the plantar plate and proper repair of these ligaments is essential.

     

    If the metatarsal bone is long, the bones are repositioned to align the foot and decrease abnormal pressure through the region. The HAT-TRICK allows for more customized and specific osteotomy of the metatarsal.

     

    Hammertoes can be the result of a chronic plantar plate issue. The HAT-TRICK incorporates an implant that allows for reduction and correction of the hammertoe deformity.

     

    Occasionally, the plantar plate may be very badly damaged and not reparable. In such cases, the flexor tendon from the bottom of the toe is wrapped around the top of the toe to hold the toe in joint. No loss of function is noted with this flexor tendon transfer. No pin is used in order to avoid arthritis and allow early physical therapy. With proper care, patients return to full activity with little to no pain.

     

    COMPLETE PLANTAR PLATE REPAIR SYSTEM (ARTHREX CPR)

    The Arthrex CPR system is a unique device for correcting a plantar plate rupture and dislocation of the metatarsal phalangeal joint.

     

    CPR offers the suture passing approach to restore the normal alignment of the joint with the anatomic repair. This procedure allows the surgeon to perform a dorsal approach (top surface of the foot) to the second toe joint which aids in visualization of the injured joint structures.

     

    Which is better, Arthrex CPR or the HAT-TRICK Procedure?


    CPR technology can be easier to use for many surgeons, there are several benefits that make the Hat-Trick MTP Joint Repair System (Smith and Nephew) better for several reasons. including:

    • CPR is utilized only for plantar plate issues where HAT-TRICK allows for repair of plantar plate and collateral.
    • Better grip of the plantar plate with the HAT-TRICK procedure.
    • THE Peek implant of the hat-trick allows sutures to be tensioned and tied into the bone, CPR does not have this.
    • For increased accuracy, the HAT-TRICK offers an osteotomy guide for metatarsal. CPR does not have this.
    • There is a faster recovery faster with HAT-TRICK because it is a more stable system and allows for earlier start to physical therapy.

     

    Plantar Plate Surgery Recovery Time

     

    Normally, the recovery after direct repair of the plantar plate (when you will be back in normal shoes again) is usually four to eight weeks.  The plantar plate is very strong ligament and it simply takes time to heal, but when it does, you will be pain-free!

     

    Wile recovering, you will need to be off the foot while healing and crutches are often suggested. You will be placed in a removable boot or a cast, depending on the extent of the surgical repair.

     

    How to Prevent Plantar Plate Tears

    Plantar plate injury, ball of foot pain, Plantar plate repair surgery

    Proper position of the toe after surgery.

    It is much more difficult to treat chronic tears of the plantar plate. Patients who recognize the symptoms of a plantar plate tear and have it evaluated by a specialist can receive the best treatment quickly, avoiding more complicated and harder to repair plantar plate tears. 

     

    If signs and symptoms of a plantar plate irritation are caught early, the prognosis of conservative treatment is improved with things such as:

     

    Custom Orthotics

    Patients with certain biomechanical factors that put additional pressure in the forefoot should have an orthotic to distribute pressure away from the problem area. Increased pressure on the forefoot from biomechanical factors such as a long 2nd metatarsal, elevated 1st metatarsal, or short 1st metatarsal, can be minimized with the proper orthotics.

     

    Athletes and runners should have their feet evaluated by a specialist to see if they are putting additional load on the forefoot. If so, custom orthotics can help prevent many issues that they may encounter, including plantar plate tears.

     

    Proper Shoes

    Certain shoes will cause increased pressure on the forefoot. Many running shoes will have a rocker forefoot that offloads pressure away from the ball of the foot. Flexible shoes, such as shoes used for barefoot running, will often put additional pressure on the forefoot, placing the patient at risk for developing a plantar plate tear.

     

    Avoid Steroid Injections into the Joint

    Many patients often just want a quick fix and will opt for an injection into the joint when the tissue is irritated. Although steroid injections can be helpful, they can weaken soft tissue structures, including the plantar plate. Steroid injections should be avoided in the lesser toe joints for this reason.

     

    Accurate Diagnosis of a Plantar Plate Tear is Critical


    Plantar plate injuries are often misdiagnosed as hammertoes, neuromas or capsulitis (inflammation of the tendons that surround the toe joints). A misdiagnosis means the true underlying condition isn’t treated and the pain and deformity will continue to worsen.

     

     

    Why UFAI the Best Choice for Plantar Plate Care?

    Expertise

    While we always exhaust conservative treatment options first, should surgery be needed, you will be in the best hands. Our physicians worked directly with manufactures in the design of two of the most revolutionary treatment products in the field today: the HAT-TRICK™ and the Complete Plantar Plate Repair System (CPR™). Our doctors are often asked speak on these technologies as well as train other foot specialists on the procedures.

     

    Technology

    Our on-site imaging includes an open MRI for the foot and ankle and weight-bearing 3D CT scan, both of which offer the most advanced diagnostics available.

     

    Quality Patient Care

    In addition to our on-site imaging, we have our own brace and orthotic manufacturing, on-site physical therapy clinic and state-of-the-art operating rooms. This allows us to coordinate all services and specialties for our patients in a single location and allows for your team of doctors and therapists to communicate directly and regularly about your treatment plan. We have treated thousands of plantar plate injuries with the highest success rates in the country.

     

    Read more about plantar plate repair in the Podiatry Today article: " Expert Insights On Treating Plantar Plate Tears" written by UFAI's Dr. Baravarian.

     

     

    Frequently Asked Questions about Plantar Plate Tears and Plantar Plate Surgery

     

    Q: What is the success rate for Plantar Plate repair surgery?

    A: UFAI's success rate is currently over 95%. The level of total correction can depend on the amount of damage but basically it is always repairable.

     

    Q: I was recently diagnosed with a non-retracted tear of the 2nd and 3rd planter plate. What does that mean?

    A:  This means that the plantar plate ligament is torn but the toe is not badly dislocated.

     

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