Plantar plate tears are a common cause of pain on the ball of the foot. They normally occur over the 2nd Metatarsal head (see the diagrams below).
What is the plantar plate?
The plantar plate is a ligamentous structure that lies beneath the metatarsophalageal joints of the lesser toes.
This supports the joints during walking and activity.
How does the plantar plate tear?
The plantar plate usually tears at its insertion to the proximal phalanx. It can tear with an injury but more commonly it tears in association with degeneration.
The second toe is the most commonly affected.
What are the symptoms of a tear?
There are a number of symptoms that indicate a plantar plate tear, the most obvious being pain and swelling under the ball of the foot. The pain can be sharp or dull, but most often it feels like there’s simply not enough cushioning in the bottom of the foot. A more gradual symptom that happens as the tear worsens is the shifting of the toe, usually the second or third toe. One or both of these toes will move towards the big toe, and the toe that’s shifting will eventually not touch the ground when the foot is placed flat on the ground.
- Pain beneath the metatarsal head, normally the 2nd and/or 3rd.
- Deformity of the toe either clawing or splaying of the toes due to the loss of the supporting function of the plate.
- Rubbing over the toe due to deformity.
- Pain and swelling over the knuckle of the metatarsophalangeal joint due to inflammation.
- Numbness in the web space (not always).
How is the diagnosis made?
- History & examination – Combined with the clinical instinct of a practitioner who is familiar with plantar plate tears.
- Ultrasound scan / imaging – Where a plantar plate tear is suspected we would arrange for an ultrasound scan to be undertaken by our ‘in house’ musculoskeletal specialist Sonographer in order to confirm the diagnosis.
Will the tear heal on its own?
If the tear occurs in degenerative tissue, which is more common, then the tissue is unlikely to heal, however the pain may subside over 6 months. If the toe has clawed then this will not correct. In younger patients where the plantar plate has no degenerative changes and has torn due to injury (stubbing of toe or repeatedly having the toe forced in a dorsi-flexed position) then healing of the damaged plate is possible depending on the extent of the damage.
What are the non surgical treatments?
Unless there is a toe deformity, one should first attempt non-surgical care. For acute pain less than three months in duration, patients may respond to strapping of the toe and the use of a stiff shoe or boot to prevent strain.
- Simple pain relief.
- Activity modification.
- Shoe modification – deep toe box, stiff ‘non bendy’ soles.
- Modified insoles – Metatarsal dome or bar (see images below).
- Toe splint.
- Corticosteroid injections – if pain is significant and surgery can not be considered, and the symptoms have not responded to other conservative regimes, then these injections can be considered by our Podiatrists. Firstly, the area is numbed with a local anaesthetic and then the podiatrist will inject a small volume of cortico-steroid solution into the affected area. This is undertaken with the assistance of our 'in house' musculoskeletal specialist sonographer using ultrasound imaging. Mark Hollinshead is our Podiatrist who undertakes these injections. These injections would normally offer significant relief of pain although they could exaggerate any pre-existing toe deformity (clawing of the toe or deviation of the toe to one side).
How about surgery?
The decision to recommend patients to consider surgery depends on many factors. If symptoms have been present for less than 3 months and there is little or no clawing of the toe or deviating of the toes position then the non surgical interventions discussed above would be advised.
If symptoms are chronic with obvious deformity of the toe and the symptoms impact on quality of life particularly if activities are being compromised then surgery could be considered. Surgeons may differ slightly in their preferences of surgical procedure however these would often include suturing the torn plantar plate back to the first bone in the toe (proximal phalanx). Additionally, the surgeon may well shorten the length of the metatarsal bone (Weil Osteotomy) to reduce pressure on the metatarsal head. Our Podiatrists will advise accordingly if they feel surgery should be considered.