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As the name suggests it is when there is an injury and damage to the plantar plate.
The plantar plate and plantar fascia resist upward (dorsal) displacement of the toe. The plantar plate is a fibrocartilaginous thickening of the plantar capsule of the MTP joint. This is continuous with the periosteum (surface layer on bone) of the base of the proximal phalanx. It is attached to the metatarsal head by the collateral ligament.
The plantar plate
Read more about the plantar plate under lesser toe anatomy and ligaments of the foot and ankle in Foot and Ankle Anatomy.
MRI of the foot – injected dye into the MTP joint is shown to leak outside the joint indicating tear in the plantar plate and capsule
The following conditions may cause plantar plate injuries:
Please read 2nd MTP joint instability and crossover toe for related information.
Pain is by far the commonest symptom. Pain may be felt in the “ball” of the 2nd toe joint, on the plantar (sole) aspect of the foot. Pain may also be felt across the dorsum (top) of the foot at the 2nd MTP joint. The pain is typically of gradual onset and has been present for over 6 months at presentation to an orthopaedic foot and ankle specialist.
Swelling may be present particularly as the condition progresses, and there may be increased warmth in the joint.
Deformity can occur as the condition progresses. The 2nd toe elevates initially, a hammer toe deformity (flexion at the PIP joint and extension at the MTP joint) frequently occurs and finally the toe crosses over.
Examination initially may reveal nothing but tenderness across the 2nd MTP joint. As the condition progresses swelling can occur, and the 2nd toe starts to drift (medially) towards the big toe. Later the 2nd toe crosses over or under the big toe. Thickening of the skin (callosity) under the 2nd MTP joint is typically a manifestation of increased load and forces going through the joint. The callosity may be painful and attempts to remove it will be temporary as the skin will thicken again in response to the abnormal load.
Your surgeon Mr Malik will look for the following on clinical examination:
Radiographs will be arranged at your initial clinic consultation. These will help confirm the diagnosis, the severity of the deformity and aid in pre operative planning.
Radiographs (x-rays) are a useful first line investigation to rule out any other problems in the forefoot. They may be normal in the early stages of the condition. The 2nd MTP joint may appear distended. In later stages of the condition there is dorsal and medial subluxation of the toe.
Radiograph of left foot demonstrating 2nd MTP joint instability
Ultrasound is used to confirm swelling (synovitis) in the 2nd MTP joint, and to see if there is anything else that may be causing the symptoms for example, Morton’s neuroma or intermetatarsal bursitis.
MRI is one of the most sensitive imaging techniques for plantar plate injury. It provides excellent high definition static images.
MRI is particularly useful in assessing:
An MRI of the foot demonstrating inflammation (synovitis) in the 2nd MTP joint
An MRI in combination with a small injection into the joint can help confirm any injury to the plantar plate (if there is a tear, fluid leaks out of the 2nd MTP joint, see image below), it can also confirm any stress lesions in the bone itself. If the underlying diagnosis is not clear an MRI can be a useful investigation.
MRI of the foot demonstrating leaking out of dye injected into the 2nd MTP joint indicating that there is a likely tear in the plantar plate and capsule
The natural history of this condition is not clearly understood.
It could be that many people with plantar plate injuries get better with time and rest and never report their symptoms to a doctor. As orthopaedic foot and ankle surgeons we are seeing more of this condition but that is probably due to increased awareness and understanding of this problem rather than a true increase in incidence of the condition.
Left untreated and despite conservative treatment plantar plate injury can progress and cause increasing pain and deformity in the foot.
The following are radiographs taken over 3 years with a patient with 2nd MTP joint instability with a plantar plate injury:
A radiograph showing a normal 2nd MTP joint
X-ray showing mild medial deviation of the 2nd toe
Subluxation at the 2nd MTP joint
MRI showing dislocation at the 2nd MTP joint with attenuation of the plantar plate
The patient eventually underwent surgical correction with a plantar plate repair and had a good result in terms of deformity correction, restoration of normal anatomy and pain relief
Non-operative management aims at relieving pain and possibly preventing disease progression. It is likely to be most effective in the early stage of plantar plate injury.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports that involve lots of turning, twisting and bending of the toes such as running, dancing, basket ball etc.
In the acute stage, RIE (rest, ice, and elevation) may help alleviate the pain.
Made of silicon can be worn over the toe to protect from direct pressure and rubbing against footwear.
Position the toe in neutral alignment using cross over taping or toe straps. Provide stability to the joint and alleviate symptoms. If there is no deformity then taping may allow healing to occur. If deformity is present, then prolonged taping will not correct this.
An example of taping which has failed to correct the deformity
An insole with a metatarsal dome pad just proximal to the 2nd MTP joint can take some of the pressure off the joint and alleviate the pain. Stiffening the area under the 2nd metatarsal head with an orthoses can reduce the forces across the 2nd MTP joint. A rocker bottom sole may also help relieve dorsiflexion of the toe, which again would reduce the forces across the 2nd MTP joint. An insole that has a recess for a callosity may also reduce pain.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from an inflamed synovitic 2nd MTP joint.
The use of stiff soled shoes that do not bend and therefore protect the 2nd MTP joint.
Stretching tight calf muscles will help reduce the forces going across the forefoot. This will help reduce pain in the 2nd MTP joint.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. In general, mild deformities can be treated by soft tissue procedures; severe deformities may require the addition of a bony corrective surgery (resetting the bone).
Please see 2nd MTP joint instability, crossover toe and hammer toe for related details of operative treatment options. Below we will discuss only the surgical procedure for plantar plate repair.
The procedure is carried under general anaesthesia. The operation will take roughly an hour. It will almost always be a daycase procedure which means you can go home the same day.
An incision is made over the top of the foot at the level of the 2nd MTP joint (most commonly involved joint). The 2nd metatarsal is shortened and the torn plantar plate identified. It is then reattached to the base of the 2nd toe.
Illustration of the key steps during a plantar plate repair operation
Animation of Plantar Plate Repair Surgery
At the time of surgery any other toe deformity such as a hammer toe and bunion will also be corrected.
It should be borne in mind that complications can result from a condition with or without surgery.
A – Clinical picture of crossover toe with corresponding B – x-ray of the foot, note severe Bunion (hallux valgus) deformity and dislocation at the 2nd MTP joint
This patient had an ulcer form at the site of their callosity which subsequently became infected
Complications can occur as with any type of surgery. Please see foot and ankle complications for more detailed explanation of post surgical complications.
Note – this list is not exhaustive and is meant as a guide.
Almost all surgical procedures for plantar plate injury will be undertaken as a day case.
You will have a bandage applied similar to this during the operation.
Post operative bandage of the foot
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.
Post operative stiff soled shoe
For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.
High elevation of the foot and ankle
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped in a toe splint.
An example of taping of the foot to help maintain the surgical correction and allow the structures to heal in the correct position
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 weeks before any driving is advisable.
Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.
Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.
You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 weeks to heal.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.
Final clinical examination. Discharge if satisfactory.
This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a stiff soled shoe with a wide toe box while your foot continues to heal.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
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info@lfaclinic.co.uk
