Plantar Plate Injury

A plantar plate injury is a surprisingly common problem and one, in my experience, that often goes undiagnosed. What is it and how can you fix it? Does it always need surgery? Let’s dig in.

What is a Plantar Plate Injury?

The toes have some special reinforcement on the bottom of the joint called the Plantar Plate. This is a thickening of the ligaments here that allows the foot to take a beating as well as limiting the amount of extension that any individual toe joint (MTP) can perform. There are other ligaments jacked in here that attach that plate to the rest of the toe joint (see blue and red highlighted ligaments here). The plate and it’s associated ligaments can get injured when there is forceful trauma to the bottom of the foot, or if the toe gets hyper-extended. This injury may be linked to “Turf Toe” which is an injury where the toe gets forcefully pushed upwards (1).

What Are the Symptoms of a Tear Here?

The most common thing patients notice after a plantar plate injury is either pain in the toe joint itself or at the bottom of the joint where the toe meets the floor. Many times this pain is confused with sesamoiditis. This is when the small bone at the bottom of the toe gets inflamed. The pain is often made worse with activity and may feel better in stiff-soled shoes as this protects the area more. Pain is more severe at “toe-off” or when you push off with your toes while walking or running.

How Is a Plantar Plate Tear Diagnosed?

MRI is the gold standard for plantar plate injury diagnosis (5). A plantar plate injury can also be diagnosed using ultrasound imaging (2). However, this type of injury usually can’t be diagnosed with x-rays. The tears in the 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?

The short answer is yes, plantar plate tears can heal on their own and that’s been reported with MRI’s confirming the healing (3, 6). This would generally take several months to a year based on what’s been reported. Physical therapy should also be a first step in trying to get these injuries to heal. Using a stiff-soled shoe or special rocker boot may help protect the area. The toe can also be taped to limit it’s upward excursion while healing. A cast is usually not required.

Do You Need Plantar Plate Surgery?

Grades 0 and 1 are usually treated with radiofrequency to heat up and scar down the loose plantar plate (7). Grades 2 and 3 are commonly treated surgically with direct suturing of the plantar plate tear, and grade 4 with a surgical tendon transfer. An osteotomy is also usually performed. This is where a wedge is cut out of the bone to tighten the ligaments around the plantar plate (7). However, a recent study showed poor results for the surgical treatment of grade 1, 3, and 4 tears. Other types of plantar plate surgical repair procedures have had mixed results with one study reporting less than stellar patient satisfaction (4).

Perc-MTP-VL Procedure

There’s a new way to treat these injuries using a precise image-guided injection of orthobiologics like your own stem cells or platelets to enhance natural healing. This procedure is known as a Percutaneous MTP Volar Ligamentoplasty (Perc-MTP-VL). This uses a combination of ultrasound and x-ray guidance to inject either high dose platelet-rich plasma or bone marrow concentrate directly into the tear to promote healing. This is a super-specialist procedure that around 100 US physicians are qualified to perform. While nothing has been published yet, we’ve been using this procedure for many years with excellent results and a fraction of the downtime of bigger surgical, or radiofrequency approaches. Watch my video below on a patient who had this procedure:

The upshot? Plantar plate injuries are tough in that they can be slow to heal and surgery doesn’t work all that well. However, newer and less invasive techniques to promote repair show promise.

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References:

(1) Nery C, Baumfeld D, Umans H, Yamada AF. MR Imaging of the Plantar Plate: Normal Anatomy, Turf Toe, and Other Injuries. Magn Reson Imaging Clin N Am. 2017 Feb;25(1):127-144. doi: 10.1016/j.mric.2016.08.007.

(2) 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.

(3) 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.

(4) Prissel MA, Hyer CF, Donovan JK, Quisno AL. Plantar Plate Repair Using a Direct Plantar Approach: An Outcomes Analysis. J Foot Ankle Surg. 2017 May – Jun;56(3):434-439. doi: 10.1053/j.jfas.2016.12.002.

(5) 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

(6) Ojofeitimi S, Bronner S, Becica L. Conservative Management of Second Metatarsophalangeal Joint Instability in a Professional Dancer: A Case Report. J Orthop Sports Phys Ther. 2016 Feb;46(2):114-23. doi: 10.2519/jospt.2016.5824.

(7) 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.