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Plantar plate tears are a frequently overlooked but painful injury of the foot. Patients may present with sudden foot pain caused by an acute injury to the plantar plate, or a gradual onset of a dull, achy sensation due to gradual damage over time.
These symptoms can significantly impact daily activities and reduce the quality of life if left untreated.
In this article, we will provide an in-depth discussion on the management of plantar plate injuries.
What Is the Plantar Plate of the Toe?
The plantar plate is a fibrocartilage structure that helps to stabilize the metatarsophalangeal joints.
The metatarsophalangeal joints are the joints that connect the base of your toes to the metatarsal heads (knucklebones).
The plantar plate is made up of several components, including the plantar fascia, collateral ligaments, deep transverse intermetatarsal ligament, interosseous tendons, and fibrous sheath of the flexor tendons (1). It is 2 to 5 mm thick, 16 to 23 mm long, and 8 to 13 mm wide (1).
It is a small, but important structure. It becomes thicker and painful secondary to repetitive trauma.
What Is the Function of the Plantar Plate in the Foot?
The plantar plate serves a crucial role in safeguarding and providing cushioning for the metatarsophalangeal joint.
Additionally, it acts as a protective barrier against excessive upward movement (dorsiflexion) and hyperextension of the toes at the joint, thus ensuring proper alignment.
When the plantar plate is damaged, it can result in the affected toe appearing elevated compared to the rest.
Although plantar plate injuries can occur in the big toe, the most common location they are seen is in the 2nd metatarsophalangeal joint.
What Causes a Tear of the Plantar Plate?
A plantar plate injury occurs when there is forceful trauma to the joints, resulting in a tear of the plantar plate.
This usually happens from a forceful dorsiflexion-type injury. It is often seen in football, soccer, and basketball players, but can occur in anyone.
Plantar plate injuries can also occur gradually over time due to repetitive microtrauma to the joint.
For instance, women who have worn high heels for many years have a higher incidence of plantar plate injuries.
This is because high-heels cause hyperextension of the toe joints.
Overtime, this hyperextension of the toes will stretch and weaken the plantar plate, causing it to eventually tear.
Plantar plate tears differ from plantar fasciitis, which is inflammation of the ligament of the arch.
What Are the Symptoms of a Plate Tear?
- Pain and bruising in the ball of the foot and the base of the toes
- Swelling in the ball of the foot and base of the toes
- Swelling that extends to the top of the forefoot
- Pain when walking and relieved with rest
- Severe pain with extension of the toe
- Numbness and tingling in the toe
- Elevation of the affected toe
- The second toe drifts towards the great toe (spreading apart from the third toe)
How Are Plantar Plate Tears Diagnosed?
If you suspect you have a plantar plate injury, start RICE therapy, and contact your foot doctor.
Your foot doctor will perform a history and physical exam. Your doctor will press on the plantar plate to confirm the location of injury.
Your doctor will perform a Lachman’s test to evaluate for plantar plate instability.
This involves pushing up on the toe to see if there is excess upward motion present at the joint. A positive test indicates that the patient has a torn plantar plate.
Your doctor will also check the alignment of your toes/feet when you stand. If the affected toe is raised in comparison to the other toes, this suggests that a plantar plate injury may be present.
Your doctor will order x-rays to rule out other causes of pain in the ball of the foot such as stress fractures.
An ultrasound can be beneficial in identifying a defect in the plantar plate, however, an MRI is more sensitive in helping identify plantar plate tears.
A Magnetic Resonance Imaging test (MRI) can identify a plantar plate tear and also help to rule out other bone and soft tissue pathologies (such as neuromas, stress fractures, and infections).
What Is the Treatment for a Plantar Plate Tear?
Conservative Therapy for Plantar Plate Injuries
The goal of treatment for plantar plate injury is to decrease pain and inflammation while allowing for the healing of the damaged tissue.
Immobilization of the joint is typically accomplished with non-weight bearing in a short leg boot or cast for 2 weeks.
Your doctor may suggest that you then bear weight in the cast boot for an additional 4 weeks before trying to transition into athletic shoes. Rocker bottom shoes work great to alleviate pressure on the ball of the foot.
You should also tape your second toe down daily to prevent the toe from elevating upwards.
The best tape to use for plantar plate tears are athletic tape or even Kinesiotape.
Here’s a video by Dr. Kevin Kirby demonstrating how to properly tape a plantar plate injury:
An insert, such as the Powerstep Pinnacle Plus orthotic that has a metatarsal pad in it can help alleviate pressure in the ball of the foot.
You can place these inserts directly into your shoes (make sure to take your shoe liner out first).
Your doctor may suggest physical therapy to help reduce pain, improve muscle strength, improve balance, and proprioception. Physical therapy would need to be completed for at least a month.
Surgery for Complete Plantar Plate Tears
If conservative therapy fails after 6 weeks, or you have a complete plantar plate tear, your doctor will suggest surgery.
This is especially important if you are an athlete and anxious to get back to activities quickly.
The surgery would be done in the operating room under anesthesia. Surgery may vary depending on your foot structure and the type of injury.
If you have a long 2nd metatarsal your doctor will choose to cut the metatarsal and shorten it. It would be fixated using screws. This is known as a “Weil osteotomy.”
Shortening the metatarsal can help realign the toe in its proper position. In addition, shortening the metatarsal can help reduce pain in the ball of the foot.
If the second digit is hammered, your doctor may choose to fuse the second toe straight. All of these procedures can be performed with one incision.
Here’s a video by Wright Medical on surgical repair of a plantar plate tear.
After surgery, you will need to remain non-weight bearing in a cast boot or splint for 6 weeks minimum, followed by gradual heel weight bearing in the cast boot for another 2-4 weeks before transitioning to athletic shoes.
You should continue to tape your toe down daily for up to 3 months after surgery to ensure it maintains proper alignment.
Untreated Plantar Plate Tears
An untreated plantar plate rupture can cause significant pain and prolonged swelling in the foot. It can be difficult to walk, and also difficult to play sports.
Not only that, your affected toe will continue to drift and elevate, and that can make wearing shoes difficult.
Overloading the ball of the foot can place you at risk for stress fractures. You may also develop toe arthritis.
How Long Is Recovery From Plantar Plate Repair?
Recovery from a plate tear can take 12 weeks in total. This is because you will need to stay non-weight bearing after a plantar plate repair surgery for 6 weeks, followed by 2-4 weeks of gradual weight bearing in a cast boot, followed by 2 weeks of transitioning to athletic shoes and physical therapy.
Can You Drive After a Plantar Plate Operation?
If you had surgery on the right foot, it’s best to avoid driving for at least 6-8 weeks minimum until the surgery site is healed to prevent tearing the plantar plate.
Putting excessive pressure on the ball of your foot can cause injury to the plantar plate. When you can transition to athletic shoes, you can ask your doctor if you can drive.
You should avoid driving while taking narcotics.
How Can You Prevent Plantar Plate Injuries?
Prevention of plantar plate injuries can be achieved through the use of proper footwear and warm-up/stretching exercises before participating in sports.
When participating in high-impact sports, it is important to wear shoes that fit well and provide support for the foot and ankle.
Warming up properly before playing sports helps to increase blood flow to the muscles and joints, making them less susceptible to injury.
Stretching exercises help to maintain flexibility in the muscles and tendons around the foot and ankle, which also decreases your risk for injury.
Avoid wearing shoes with excessively high heels. Wear shoes with stiff soles. This can help prevent hyperextension of the toe joints.
What Shoes Are the Best Shoes for Plantar Plate Tears?
Rocker-Bottom Shoes
Individuals with plantar plate tears may benefit from wearing rocker-bottom shoes. These shoes have a curved sole that promotes a rolling motion of the foot and can help reduce pressure on the forefoot.
Examples of rocker bottom shoes that may be suitable for those with plantar plate tears include the Hoka One One Bondi and the Brooks Addiction Walker.
Best Running Shoes for Plantar Plate Tears
Individuals with plantar plate tears may benefit from wearing running shoes that offer ample arch support, cushioning, and stability features.
Three popular running shoes that may be suitable for those with this condition include the Brooks Adrenaline GTS, Asics Gel-Kayano, and Saucony Guide.
Best Sandals for Plantar Plate Tears
Sandals with a supportive foot bed and arch support can be beneficial for those with plantar plate tears.
Examples of brands that offer such sandals include Birkenstock and Vionic. It is important to ensure that the sandal fits properly and offers adequate support to avoid exacerbating the injury.
Physical Therapy and Exercises for Plantar Plate Tears
Physical therapy and targeted exercises can be effective in treating plantar plate tears. A physical therapist can work with patients to develop a customized exercise plan that focuses on strengthening the muscles and tendons in the foot, improving range of motion, and reducing pain and inflammation.
Exercises may include toe curls, calf stretches, and other foot-strengthening activities.
What to Do if the Plantar Plate Injury Is Not Healing
If a plantar plate injury is not healing, it’s important to see a foot and ankle specialist who will recommend a treatment plan such as rest, physical therapy, orthotics, or surgery.
Repeat surgery may also be necessary in some cases, so it’s important to follow the specialist’s recommendations for proper healing and to prevent further damage.
Conclusion
In conclusion, plantar plate tears are a common injury that can cause significant pain and discomfort for patients. Early diagnosis is crucial, as delaying treatment can lead to further complications.
It is important for patients to seek medical attention at a healthcare provider’s office if they suspect a plantar plate tear, as prompt treatment can lead to a faster recovery and better outcomes.
With proper care and management, many patients with plantar plate tears can return to their normal activities.
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References
- Nery, C., Umans, H., & Baumfeld, D. (2016, April). Etiology, clinical assessment, and surgical repair of plantar plate tears. In Seminars in musculoskeletal radiology (Vol. 20, No. 02, pp. 205-213). Thieme Medical Publishers.https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0036-158111
- Watson, T. S., Reid, D. Y., & Frerichs, T. L. (2014). Dorsal approach for plantar plate repair with Weil osteotomy: operative technique. Foot & Ankle International, 35(7), 730-739.https://journals.sagepub.com/doi/abs/10.1177/1071100714536540
- Nery, C., Coughlin, M. J., Baumfeld, D., & Mann, T. S. (2012). Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. Foot & Ankle International, 33(4), 301-311.https://journals.sagepub.com/doi/abs/10.3113/fai.2012.0301
- McAlister, J. E., & Hyer, C. F. (2013). The direct plantar plate repair technique. Foot & Ankle Specialist, 6(6), 446-451.https://journals.sagepub.com/doi/abs/10.1177/1938640013502723
- Maas, N. M., van der Grinten, M., Bramer, W. M., & Kleinrensink, G. J. (2016). Metatarsophalangeal joint stability: a systematic review on the plantar plate of the lesser toes. Journal of foot and ankle research, 9(1), 1-10.https://link.springer.com/article/10.1186/s13047-016-0165-2
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