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Plantar Plate Tear

Causes, Symptoms, Treatments, & Other Resources

Foot pain can be debilitating making a simple step almost impossible.  What is the plantar plate?  What causes plantar plate tears?  Is a plantar plate tear painful?  How is a plantar plate tear diagnosed?  How do you treat it?  Are there new, nonsurgical treatment options?  Let’s dig in.

What Is the Plantar Plate? visual representation of plantar tear

The plantar plate is a fibrocartilage structure located at the ball of the foot.  The ball of the foot involves a joint which anatomically is called the metatarsal phalangeal joint (MTP) joint.  The MTP joint is where the long foot bone (metatarsal) meets the toe (phalanx).

Each toe in the foot has an MTP joint which is numbered 1 through 5.  The plantar plate allows the foot to absorb the enormous forces of walking and running in addition to limiting extension (1).  There are ligaments that attach the plantar plate to the long bones of the foot which are illustrated by the red and blue bands in the picture.  The plantar plate and the supporting ligament provide critical stability for the MTP joint.

What Causes a Plantar Plate Tear?

The plantar plate is susceptible to injury and can involve the tearing or rupture of the plantar plate.   Plantar plate tears are a common injury in the foot which is caused by repetitive overload.   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 (2)  Plantar plate injuries cause instability in the MTP joint.

The second toe joint (MTP) is the most frequently affected joint and has a high incidence in women over the age of 50 years of age (3).  The second MTP joint accounts for 63-90 percent of all plantar plate tears (4).   Numerous terms are used to describe this condition which includes metatarsalgia, pre-dislocation syndrome, lesser metatarsophalangeal joint (MTPJ) instability, and crossover toe deformity (2).

Is a Plantar Plate Tear Painful? And What Other Symptoms Are There?

Yes!  The most common symptoms are tenderness or pain at the MTP joint, swelling, and misalignment of the affected toes (5).  Pain is typically made worse when the toes meet the floor and walking.

How Is a Plantar Plate Tear Diagnosed?

There are a number of specific physical examination tests to identify tears in the plantar plate.   MRI is the gold standard for plantar plate injury diagnosis (6).  Ultrasound can also be used to diagnose a plantar plate tear (7).  Tears in the plantar plate are graded 0-4 based on severity. The least severe is a grade 0 where the fibers of the plate are stretched.

In a grade 1 tear, less than 50% of the plate is torn, whereas in a grade 2 more than 50% is torn.  Grade 3 is more extensive and involves the collateral ligaments.  Grade 4 is is a complete disruption and dislocated.

Can a Plantar Plate Tear Heal on its Own?

Tears in the plantar plate can heal on their own, if small.  Studies using MRI imaging have demonstrated plantar plate healing (8)  Healing can take months and up to a year.

Plantar Plate Tear Treatment

Conservative Care

Physical therapy is the first line of treatment when appropriate.  Treatment options may include foot elevation, taping, immobilization, shoe wear modifications, metatarsal pads, and custom-made orthoses (9)

Surgical

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) (10).  Plantar plate tears grades 0-1 are typically treated with radiofrequency to tighten the capsule and scar down the loose plantar plate (11).  Treatment for Grades 2 and 3 involve sewing together the tear.  Grade 4 tears typically involve a tendon transfer and osteotomy.

The latter is where a section is cut out of the bone in order to tighten the ligaments around the plantar plate.  Complications occur and involve bleeding, infection, and continued pain, and toe misalignment.  Patient satisfaction was mixed in a recent study (9).  Operative treatment may consist of an indirect reconstruction of the MTP joint in which the toe is realigned without reconstruction of the plantar plate (12).

New Treatment Option plantar plate tears

There is a nonsurgical treatment option with a precise ultrasound-guided injection of platelets and or bone marrow concentrate to enhance your natural healing.  The procedure is called  Percutaneous  MTP Volar Ligamentoplasty ( Per-MTP-VL).  This involves the use of ultrasound and x-ray guidance to inject a patient’s own platelets or bone marrow concentrate directly into the tear.  The image to the right is an ultrasound image of a plantar plate tear recently treated in the clinic.  This is a complicated and highly skilled procedure that neither your PCP nor orthopedic surgeon can perform.  At the Centeno-Schultz Clinic, we are experts in the management and treatment of foot and ankle injuries including plantar plate tears.  Using the Per-MTP-VL has afforded our patients a non-surgical treatment option for plantar plate tears without the risks and downtime associated with surgery and radiofrequency procedures.  Below is a testimony from a patient who underwent the procedure and was able to return to his passion.

In Conclusion

The plantar plate is fibrocartilage structure located at the ball of the foot.  The ball of the foot involves a joint which is called the MTP joint. The plantar plate lies immediately beneath the MTP and functions to absorb the enormous forces of walking and impact.  It also provides critical support to the MTP joint. The plantar plate is susceptible to injury due to repetitive overload and typically results in pain and swelling of the affected MTP joint.  injuries are graded from 0-4.  Injury of the plantar plate causes instability of the MTP joint. Treatment options include conservative care and surgery.  A new novel procedure that uses a patient’s own platelets or bone marrow is a non-surgical treatment option for those with plantar plate tears who wish to avoid the risks of surgery and the required rehabilitation.

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Our Doctors Who Treat Plantar Plate Tears

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

My passion and specialization are in the evaluation and treatment of cervical disc, facet, ligament and nerve pain, including the non-surgical treatment of Craniocervical instability (CCI). I quit a successful career in anesthesia and traditional pain management to pursue and advance the use of PRP and bone marrow concentrate for common orthopedic conditions. I have been a patient with severe pain and know firsthand the limitations of traditional orthopedic surgery. I am a co-founder of the Centeno-Schultz Clinic which was established in 2005. Being active is a central part of my life as I enjoy time skiing, biking, hiking, sailing with my family and 9 grandchildren.

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Matthew William Hyzy, D.O.

Doctor Hyzy is Board Certified in Physical Medicine and Rehabilitation (Physiatry) and fellowship-trained in Interventional Orthopedics and Spine. Dr. Hyzy is also clinical faculty at the University of Colorado School of Medicine in the Department of Physical Medicine and Rehabilitation; In addition, Dr. Hyzy is an Adjunct Clinical Assistant Professor at The Rocky Vista University College of Osteopathic Medicine. Dr. Hyzy also maintains an active hospital-based practice at Swedish Medical Center and Sky Ridge Medical Center. He is also recognized and qualified as an expert physician witness for medical-legal cases and Life Care Planning. He is published in the use of autologous solutions including…

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Mairin Jerome, MD

Mairin Jerome, MD

Dr. Mairin Jerome is a physiatrist with subspecialty fellowship training in Interventional Orthopedics and Regenerative Medicine. This subspecialty serves to fill the gap for patients who are interested in therapeutic options that lie between conservative treatment and surgery. Dr. Jerome uses regenerative medicine techniques, including prolotherapy and orthobiologics, via X-ray or ultrasound guidance to precisely deliver injections to areas of musculoskeletal injury or degeneration. Orthobiologics refers to tissue harvested typically from a person’s own body, such as platelets (platelet-rich plasma, PRP) or bone marrow, for use in treating painful musculoskeletal conditions. The goal is to stimulate the body’s healing mechanisms to improve pain, function, and decrease inflammation.

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Other Resources for Foot Pain

  • Stem Cell Treatment for Foot Pain: Learn the Truth.

    Foot pain can be debilitating. Dr. Schultz discusses the 7 major causes of foot pain, traditional treatment options, stem cell treatment options, the different types of stem cells, factors that will influence the specific stem cell treatment plan, and the advantages of stem cells over steroids and surgery.


  • Tibial Nerve Injury: Symptoms, Diagnosis, and Treatment Options

    Dr. Markle discusses tibial nerve injury – what that means, when you need surgery, and how to avoid surgery. Transcript: Introduction Hello, Dr. Markle of Centeno-Schultz Clinic, and today we’re going to be talking about how to treat tibial nerve injury. We’ll be discussing exactly what is the tibial nerve, the muscles the tibial innervates, … Continued


  • Morton’s Toe & Morton’s Neuroma: What Are They, and What Treatments Are Available?

    Morton’s Toe vs. Morton’s Neuroma – A small course on what they are and what can be done to treat them.  Transcript Dr. John Schultz Hi, everybody. This is Dr. Schultz with the Centeno-Schultz Clinic. I thought we’d have a little fun today. You know, summer’s here and we’re having fun. Some of us are … Continued


  • 3 Things to Know About Navicular Bone Pain

    Foot pain can be crippling.  Where is Navicular Bone?  Why Does my Navicular Bone Hurt?  How do you treat Navicular bone pain?  Let’s dig in. Where is Navicular Bone? There are 26 bones in the foot.  The Navicular Bone is a small C-shaped bone located on the inside portion of the midfoot.  It is nestled … Continued


  • PRP for Plantar Fasciitis

    Dr. Pitts discusses PRP for Plantar Fasciitis, how it compares to steroid injections, and 3 studies of PRP.  Transcript Hello everybody, this is Dr. John Pitts from the Centeno-Schultz Clinic. Today, I’d like to talk about PRP for plantar fasciitis. So, in short: yes, PRP can be used for plantar fasciitis. But let’s talk about … Continued


  • Life After Talonavicular Fusion: What Do You Know About this Surgery?

    Ankle pain can be excruciating often times making a simple step almost impossible.  What is a Talonavicular fusion?  What are the indications for a Talonavicular fusion?  What are the complications from a Talonavicular fusion?  What does life look like after talonavicular fusion?   Let’s dig in. Foot Anatomy The foot is compromised of  26 bones.  The … Continued



References

1.  Johnston RB, Smith J, Daniels T. The plantar plate of the lesser toes: An anatomical study in human cadavers. Foot Ankle Int. 1994; 15(5):276–82.

2. Nery C, Coughlin MJ, Baumfeld D, et al. MRI evaluation of the MTP plantar plates compared with arthroscopic findings: A prospective study. Foot Ankle Int. 2013; 34(3):315-322.

3. Nery C, Coughlin MJ, Baumfeld D, Mann TS. Lesser metatarsophalangeal joint instability: Prospective evaluation and repair of plantar plate and capsular insufficiency. Foot Ankle Int. 2012; 33(4):301-311.

4.Umans H, Srinivasan R, Elsinger E, Wikde GE. MRI of lesser metatarsophalangeal joint plantar plate tears and associated adjacent interspace lesions. Skeletal Radiol. 2014; 43(10):1361-1368.

5.Nery C, Coughlin MJ, Baumfeld D, et al F. Classification of metatarsophalangeal joint plantar plate injuries: history and physical examination variables. J Surg Orthop Adv. 2014; 23(4):214-223.

6.Duan X, Li L, Wei DQ, et al. Role of magnetic resonance imaging versus ultrasound for detection of plantar plate tear. J Orthop Surg Res. 2017;12(1):14. Published 2017 Jan 21. doi: 10.1186/s13018-016-0507-6

7.Stone M, Eyler W, Rhodenizer J, van Holsbeeck M. Accuracy of Sonography in Plantar Plate Tears in Cadavers. J Ultrasound Med. 2017 Jul;36(7):1355-1361. doi: 10.7863/ultra.16.06067.

8. Jordan M, Thomas M, Fischer W. Nonoperative Treatment of a Lesser Toe Plantar Plate Tear with Serial MRI Follow-up: A Case Report. J Foot Ankle Surg. 2017 Jul – Aug;56(4):857-861. doi: 10.1053/j.jfas.2017.02.016.

9. Prissel MA, Hyer CF, Donovan JK, Quisno AL. Plantar Plate Repair Using a Direct Plantar Approach: An Outcomes Analysis. J Foot Ankle Surg. 2017;56(3):434-9.

10. Whipple TL. From mini-invasive to non-invasive treatment using monopolar radiofrequency: the next orthopedic frontier. Orthop Clin North Am. 2009;40:531–535. doi: 10.1016/j.ocl.2009.06.006.

11. Nery C, Coughlin MJ, Baumfeld D, Raduan FC, Mann TS, Catena F. Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears. Foot Ankle Int. 2014 Sep;35(9):876-85. doi: 10.1177/1071100714539659.

12. Gazdag A, Cracchiolo 3rd A. Surgical treatment of patients with painful instability of the second metatarsophalangeal joint. Foot Ankle Int. 1998;19(3):137–43.

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