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.
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?
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.
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
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)
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).
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 or 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 nonsurgical 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.
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 absorbs 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 nonsurgical treatment option for those with plantar plate tears who wish to avoid the risks of surgery and the required rehabilitation.
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. 11.8. 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.