What Is a Plantar Plate Tear?

The plantar plate is a ligament in the ball of your foot that supports the metatarsophalangeal (MTP) joints under the toes. The plantar plate can tear due to overuse and certain activities like running, walking barefoot on hard surfaces, and wearing high-heeled shoes for a long period of time. In the early stages, you may experience mild symptoms of dull or sharp pain under the toe. Over time, the pain can get worse and lead to crossover toe deformity, joint erosion, and arthritis. Plantar plate tears are most common in the MTP joint of the second toe.

Symptoms

Your symptoms may change depending on the stage of the injury. Some patients feel sudden pain during an injury or a certain activity, while other patients feel the pain develop more gradually.

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 a little bit, or that you have trouble gripping with that toe. In severe cases, you may have difficulty fitting into shoes.

Causes

A plantar plate tear can occur due to running in shoes that fit poorly, walking barefoot, or participating in high-loading and high-impact exercises. Direct, repetitive impact forces the toe to bend excessively, which increases pressure on the plantar plate. Having a long second toe or a bunion, or wearing narrow shoes may also contribute to the injury.

Diagnosis

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.

Treatment

Your foot and ankle orthopaedic surgeon will determine the best course of treatment depending on the severity and grade of the tear.

Non-surgical Treatment

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, like hiking boots or stiff running shoes). Full-length carbon fiber inserts can also help stiffen up your shoes. These inserts are best placed underneath the insert that comes in the shoe.

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.

Surgical Treatment

Surgery may be necessary if the toe is stiff with an old injury or if the toe remains painful with deformity after non-surgical treatment. 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 done at ambulatory surgery centers. 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 (more common) or through an incision under the ball of your foot (less common). Your foot and ankle orthopaedic surgeon may need to cut the metatarsal bone to reach the ligament, and in some cases, they will also shorten the metatarsal bone to help take pressure off the joint. Sutures are used to repair the plantar plate, often through small bone tunnels in the bone of your toe. A pin is placed across the toe to protect the repair. Typically, your surgeon will remove this pin in the office approximately 6 weeks after surgery. The pin prevents the toe from bending and protects the repair while it's healing.

  • 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. As with plantar plate repair, a pin is usually used to hold the toe in place while the tendon transfer heals.

Some newer, minimally invasive techniques have been developed to address toes that are deformed because of plantar plate injury; however, these are not common.

Recovery

It can take several weeks 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 shoe for at least a few weeks.

If any pins were inserted during surgery to hold the toe in place, they will be removed by your surgeon in the office, usually 6 weeks after surgery. It is important to wear the shoe as long as you have pins in place because walking without the shoe may break the pin.

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.

Risks and Complications

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.

Can a plantar plate tear get worse if it’s not treated?

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.

What can I do to prevent a plantar plate tear?

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

The American Orthopaedic Foot & Ankle Society (AOFAS) offers information on this site as an educational service. The content of FootCareMD, including text, images, and graphics, is for informational purposes only. The content is not intended to substitute for professional medical advice, diagnoses or treatments. If you need medical advice, use the "Find a Surgeon" search to locate a foot and ankle orthopaedic surgeon in your area.