The plantar plate is a ligament (structure that connects two bones together) in the ball of your foot that supports the metatarsophalangeal (MTP) joints where your toes connect to your foot. When the plantar plate tears, the toe can become unstable and begin to move out of its normal alignment since the connection between bones is no longer stable. Plantar plate tears are most common in the second toe.
Your symptoms may change depending on the stage of the injury. Early on you may experience subtle pain under the toe that gets worse with certain activities. You may also feel a knot or swelling in that area that feels like you are walking on marbles. Later, you may see your second toe start to move towards the big toe and even overlap, causing a “V”-shaped space between the second and third toes. You may also notice that the toe is raised above the floor, or that you have trouble gripping with that toe. As the toe moves away from the ground, you may develop a hammertoe. In severe cases, you may have difficulty fitting into shoes.
The cause of a plantar plate injury is not always known. You may be predisposed to the injury if your second toe is longer than the surrounding toes. Shoes and specific exercises have not been shown to cause the injury, but any activities or shoes that force the toe to bend away from the ground may contribute to the weakening of the plantar plate.
An example of a plantar plate injury, in which the second toe has crossed over the big toe.
See your foot and ankle orthopaedic surgeon if you are experiencing pain under your toe or other symptoms. Your surgeon will perform an examination by moving the affected toe. You may need additional tests and imaging, such as X-rays and/or MRI scans.
Your foot and ankle orthopaedic surgeon will determine the best course of treatment depending on the severity and grade of the tear.
In the early stages, resting, icing, and compressing (taping/bandaging) the toe can help. Your surgeon may recommend taking over-the-counter pain medication along with wearing a stiff-soled shoe (a shoe that does not bend at the toe, such as hiking boots
or stiff running shoes). Orthotics may be prescribed to stiffen the sole of your shoe. In addition, wide shoes and shoes with a deeper toe box may be helpful.
Your surgeon may also demonstrate a specific taping technique that will hold the toe in a good position and help relieve pain. Over-the-counter toe splints can also help hold the toe down and reduce pain. Once your condition improves, your surgeon will guide your return to activities including sports participation. Successful treatment can take several weeks or months.
Surgery may be recommended if the toe remains painful with deformity after non-surgical treatment or is too stiff to treat non-surgically. There are various surgical techniques that can be performed to repair the plantar plate tear, correct the toe deformity, and relieve pain. Most of them are same-day surgeries. Your surgeon will explain your options and recommend a treatment plan based on the severity of the injury and your goals.
Generally, there are two types of surgeries for plantar plate injuries:
Plantar plate repair
This is done either through an incision on the top of your toe or through an incision under the ball of your foot. Your foot and ankle orthopaedic surgeon may need to cut
the metatarsal bone to correct the alignment, and in some cases, they will also 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.
Tendon transfer
If the plantar plate tear happened a long time ago or your surgeon feels it cannot be repaired, then your surgeon may recommend a tendon transfer.
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.
Some newer, minimally invasive techniques have been developed to address toes that are deformed because of plantar plate injury; however, these are not common.
It can take several weeks to months to recover depending on the type of surgery you have. You may have to be non-weightbearing (keep all weight or some weight off the leg) for a short period of time to protect the repair. Most patients will be in a postoperative or protective shoe for an extended period of time depending on the severity of the injury and the surgery required.
If any pins were inserted during surgery to hold the toe in place, they may be removed by your surgeon in the office, usually 6 weeks after surgery
Some patients may need physical therapy to get the toe back to full function and strength. Even when you are fully recovered, it is likely that the toe will feel stiffer than it did before.
While most people get better after these surgeries, not everyone does well. Risks of these surgeries include wound healing issues, nerve injury (numbness/tingling in the toe), infection, and stiffness in the toe. The risks may be higher if there is history of cigarette use or autoimmune conditions.
Yes. If left untreated, the pain and deformity may worsen over time. Make an appointment with a foot and ankle orthopaedic surgeon if you suspect you have a plantar plate injury.
Make sure to wear comfortable shoes that fit well. Also, it is important to watch your toe closely after any injury or trauma for pain or swelling.
Original article by Vinayak M. Sathe, MD
Reviewers/Contributors: David Porter, MD, PhD; Elizabeth Cody, MD; Paul Ryan, MD
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