Experienced most by middle aged women whose feet have a tendency to over-pronate or roll in, a plantar plate tear is often a cause of persistent pain and swelling in the ball of the foot. It is also commonly associated with a bunion and a hammer toe. The plantar plate is a thick ligament type structure with attachments, which insert into the base of our phalanges (toe bones), in the area of the ball of the foot. The plantar plate is designed to protect the head of the metatarsal from pressure, and prevent over extension of our toes. It also plays a role in preventing our toes from spreading.

Symptoms

 Persistent pain and swelling under the ball of the foot, extending towards the toes, (most commonly the 2^nd or 3^rd). The pain can be described as a dull ache or a sharp pain, and it may feel as though there is not enough cushion between the bone and the ground. Often a sensation of ‘walking on the bones of the foot’ will be described. Some swelling may be visible on the top of the foot, along with redness. A tear will result in the toes spreading and clawing.

Over time, as the tear increases, the toe will begin to shift upwards or to one side, especially the 2nd toe moving towards the great toe. When the foot is placed on the ground, the toe may not touch. When the toe is elevated in this way, more pressure is placed onto the head of the metatarsal, causing bone bruising and pain.

If the plantar plate tear is not treated properly, the condition becomes chronic and the deformity can be greater. As the deformity progresses, the cartilage in the joint can become eroded, leading to arthritis and increased pain. Furthermore, further damage to the plantar plate may cause the toe to dislocate out of joint resulting in a more difficult surgical correction.

Causes

Although plantar plate tears can occur acutely through a stubbing injury, they most often develop slowly over time from a progressive degeneration of the ligament, from repetitive overuse, or biomechanical abnormalities.

Biomechanical abnormalities include a short or elevated 1st metatarsal, or a long 2nd or 3rd metatarsal. These abnormalities put constant pressure on the plantar plate and contribute to its degeneration.

Bunions can also put increased pressure on the plantar plate. Large bunions that push on the 2nd toe, can eventually under-lap the toe, causing it to dislocate. This dislocation is caused by thinning and stretching of the plantar plate, a result of the pressure from the bunion.

Steroid injections can occasionally cause weakening and thinning of the plantar plate ligament. Patients who have steroid injections to help relieve pain in the ball of the foot, may have noticed increasing deviation of the affected toe after the injection

 Diagnosis

Your doctor or podiatrist will move and manipulate the troubled toe joint into several different positions, to evaluate the amount of deformity and the location of the pain. Diagnosis of a plantar plate tear can often be challenging due to the complex nature of the anatomy of the foot. Careful history taking and an examination of the area of pain is required to determine the extent and cause of the tear. If necessary, further investigations such as x-rays show the degree and angles of the deformity, as well as any arthritis in the joint. In some cases, a special x-ray with a dye is injected into the joint to find the tear in the ligament. A diagnostic ultrasound or MRI may be ordered to help evaluate the severity of the damage or problem.

 Conservative Treatment

Initial treatment – Will focus on symptom relief, which may involve the use of anti-inflammatory medications, strapping of the toe, off-loading padding, altered footwear and activity modification.

Secondary treatment – Will focus on the underlying causes of the problem, such as flat feet, bunions and hammer toes. Your podiatrist will perform a thorough biomechanical assessment to determine the best course of action to offload the forefoot, and decrease the mechanical stress on the area. This injury usually occurs gradually and is best treated in the early stages. Often a customised, soft, full length orthotic and footwear modifications can prevent the problem from progressing.

Prevention

Relates to the proper position of the toe after surgery. It is much more difficult to treat chronic tears of the plantar plate. Patients who recognise the symptoms of a plantar plate tear and have it evaluated by a specialist can receive the best treatment quickly, avoiding more complicated and harder to repair plantar plate tears.

If signs and symptoms of a plantar plate irritation are caught early, the prognosis of conservative treatment is improved with things such as:

 Custom Orthotics 

Patients with certain biomechanical factors that put additional pressure in the forefoot should have an orthotic to distribute pressure away from the problem area. Increased pressure on the forefoot from biomechanical factors such as a long 2nd metatarsal, elevated 1st metatarsal, or short 1st metatarsal, can be minimised with the proper orthotics.

Athletes and runners should have their feet evaluated by a specialist to see if they are putting additional load on the forefoot. If so, custom orthotics can help prevent many issues that they may encounter, including plantar plate tears.

Proper Shoes

Certain shoes will cause increased pressure on the forefoot. Many running shoes will have a rocker forefoot that offloads pressure away from the ball of the foot. Flexible shoes, such as shoes used for barefoot running, will often put additional pressure on the forefoot, placing the patient at risk for developing a plantar plate tear.

Surgery

Occasionally surgery needs to be performed, either frank repair of the plantar plate or in chronic cases a resection osteotomy may be suggested.

Expected outcome

Treatment for this acute condition can take time, with most patients pain free with 3-4 months. Initial symptoms improvement allows most people to return to activity within 1 month.

Your feet mirror your general health . . . cherish them!