On the bottom of the four lesser toe joints, the plantar plate between the base of the toe and the metatarsal bone behind the joint is responsible for keeping the toe in the joint, especially during walking or running when the toes bend at the base of the foot before they push off from the ground. It also brings the toe back to a straight position. Unlike most other ligaments, there is no muscle associated with the plantar plate. The second toe joint is the most frequently affected joint and has a high incidence in women over the age of 50 years. The second toe joint accounts for 63-90 percent of all plantar plate tears.
What does a torn plantar plate feel like?
The plantar plate provides stability and support to the ball of the foot and helps to maintain the arch. In some instances, the ligament tears or becomes overstretched, causing pain, swelling, and instability in the affected foot, leaving the individual with the sensation of “walking on a marble”. Untreated, it can lead to toe dislocation, hammertoes, arthritis, and other painful long-term problems. It requires prompt medical attention to diagnose the problem because a plantar plate tear often gets confused with other conditions, such as neuromas due to similar symptoms.
Why does a plantar fascia tear?
Plantar plate tears can be caused by any repetitive overload of the plantar plate or by any sudden over-load of the plantar plate, such as a sudden increase in running volume or changing from rear-foot to forefoot running. A bunion or a hammertoe or poor pronation control can create an overload of the 2-5th metatarsals, causing excess pressure and an eventual plantar plate tear. Having irregular metatarsal (toe) lengths can also cause excess pressure through the plantar plate or having a history of cortisone injections to the forefoot can weaken the plantar plate, making it more susceptible to a tear. In fact, any activities or shoes that force the toe to bend away from the ground may contribute to the weakening of the plantar plate. Activities thought to increase the risk of this injury include walking barefoot on hard surfaces, wearing high-heeled shoes, and high-impact activities such as running and jumping.
How do you test for a plantar plate tear?
If you are experiencing pain under your toe or other symptoms, you should see a foot and ankle orthopedic surgeon. Your surgeon will perform a physical examination by moving the affected toe and asking questions about your medical history and lifestyle. MRI is the gold standard for plantar plate injury diagnosis. Ultrasound can also be used. Tears in the plantar plate are graded 0-4 based on severity.
- In a Grade 0 tear, the fibers of the plantar plate are stretched.
- In a Grade 1 tear, less than 50% of the plate is torn.
- In a Grade 2 tear, more than 50% is torn.
- In a Grade 3 tear, the tear is more extensive and involves the collateral ligaments.
- In a Grade 4 tear there is complete disruption and dislocation.
How do you fix a plantar plate tear without surgery?
In the early stages of treatment, your surgeon may recommend:
- Resting the affected foot
- Icing the affected toe
- Compressing the foot/toe with taping/bandaging. Your surgeon may demonstrate a specific strapping or taping technique that will hold the toe in a good position and help relieve pain.
- Taking over-the-counter pain medication
- Wearing a stiff-soled shoe (a shoe that does not bend at the toe, such as hiking boots or stiff running shoes).
- Wearing orthotics to stiffen the sole of your shoe.
- Wearing wide shoes and shoes with a deeper toe box
- Wearing over-the-counter toe splints to hold the toe down and reduce pain
- No barefoot walking/activity modification
- Stretching / Strengthening exercises to reduce tightness within the calf muscles
- Steroid injections
Is surgery necessary for plantar plate tear?
Surgery may be recommended if the toe remains painful with deformity after non-surgical treatment or if the toe is too stiff to treat non-surgically. There are various surgical techniques that can be performed to repair the plantar plate tear, correct toe deformity, and relieve pain. Most of them are outpatient surgeries. Your surgeon will recommend a treatment plan based on the severity of the injury and your particular overall health.
Radiofrequency is a medical technique that uses high temperatures in an injured area to trigger a healing response and shrink the capsule (the envelope that surrounds the joint). Plantar plate tears grades 0-1 are typically treated with radiofrequency to tighten the capsule and scar down the loose plantar plate. Treatment for Grades 2 and 3 involve sewing together the tear. Grade 4 tears typically involve a tendon transfer and osteotomy where a section is cut out of the bone in order to tighten the ligaments around the plantar plate.
The two types of surgeries for plantar plate injuries that are commonly recommended are:
- Plantar plate repair is done either through an incision on the top of your toe or through an incision under the ball of your foot. The surgeon may need to cut the metatarsal bone to correct the alignment, and in some cases, shorten the metatarsal bone to help take pressure off the ball of your foot. In order to protect the repair after surgery, you may have dressings and/or a removable pin for several weeks after surgery.
- A tendon transfer is usually recommended if the plantar plate tear happened a long time ago or your surgeon feels it cannot be repaired. There are various types of tendon transfers. The most common transfer involves taking a tendon that bends the toe and transferring it to the top of the toe. This helps hold the toe down.
What is the success rate of plantar plate surgery?
Some newer, minimally invasive techniques have been developed to address toes that are deformed because of plantar plate injury; however, these are not common. There is also a nonsurgical treatment option with a precise ultrasound-guided injection of platelets and or bone marrow concentrate to enhance natural healing. The procedure is called Percutaneous MTP Volar Ligamentoplasty (Per-MTP-VL) and involves the use of ultrasound and x-ray guidance to inject a patient’s own platelets or bone marrow concentrate directly into the tear. This is a complicated and highly skilled procedure that only a specially trained surgeon can perform.
Tears in the plantar plate can heal on their own, if small and if the patient adheres closely to the doctor’s treatment plan. Studies using MRI imaging have demonstrated plantar plate healing, but healing can take several months and up to a year. Once your condition improves, your surgeon will guide your return to activities including sports participation. Visit our blog more information on foot health issues.
