A torn plantar plate is a common cause of toe pain in the lesser toes (2nd-5th). A plate tear often causes pain and swelling at the toe’s base. Untreated, a plantar plate tear can lead to persistent toe pain and deformity. So, how do you diagnose a plantar plate tear, and what do you do to treat it?
What is a plantar plate?
The plantar plate is a strong ligament that starts from the deep surface of the metatarsal head of the toe and attaches to the undersurface of the proximal phalanx. Its primary function is to support the metatarsophalangeal (MTP) joint. Failure of the plantar plate leads to drifting or overextension of the toes.
Torn plantar plate symptoms
Generally, injuries to the plantar plate occur gradually over time. Increased forces on the plate lead to weakening and tearing.
Examples of factors that increase forces on the plantar plate include :
- Hallux valgus (or bunion toe), resulting in less pressure through the first toe and greater force on the lesser toes
- A longer 2nd or 3rd toe producing greater force on the plantar plate of the longer toe
- Excessive use of high heels increases the forces on the plantar plate
Sometimes, the plantar plate can rupture suddenly after stubbing the tip of the toe or jumping and landing on the toes. Also, a cortisone injection into the MTP joints can weaken the plantar plate, leading to sudden rupture.
How to diagnose plantar plate tear
Generally, pain is sharp and localised to the undersurface of the toe (near the ball of the foot). Pain is sometimes present on the dorsal or top part of the toe. Usually, pain is worse after weight-bearing activities such as running, dancing, or barefoot walking. Wearing high heels will make the pain of a plantar plate injury worse.
It is essential to examine the toe to determine the involvement and stability of the plantar plate. Signs of a plantar plate rupture include the following:
- Tenderness on palpation of the undersurface of the toe
- A stress test of the toe, also called a Lachman’s test, reveals more significant movement of the affected toe than other toes.
- The power of plantarflexion of the toe is reduced. Power can be tested by asking the patient to push down on the undersurface of the toe while standing. The strength to push down is significantly reduced in a plantar plate tear.
- In more advanced cases, the toe can deform. The toe can drift to one side and bunch up (like a hammertoe) to produce the Churchill sign. An example of the Churchill sign is below, with the third toe drifting toward the fourth toe.
In cases of suspected plantar plate rupture, we use imaging to diagnose and stage the rupture. Imaging is also helpful in excluding other causes of toe pain, such as inflammatory arthritis, Morton’s neuroma, or stress fracture of the metatarsal bones.
Weight-bearing X-rays will outline the bone’s alignment and exclude toe deformities such as a dislocated MTP joint, hammer toe, or floating toe.
Ultrasound or MRI outlines the structure of the plantar plate and demonstrates a partial or complete tear. There is much debate about whether MRI or ultrasound better detect plantar plate rupture. Overall, a 3T MRI is currently better. In a study comparing the two, MRI detected more cases and was more accurate.
Torn plantar plate treatment
Generally, we want to reduce the forces on the plantar plate for plantar plate ruptures to allow healing and prevent deformities such as hammer or floating toe.
We start with activity modification and simple treatments for the first six weeks that include the following:
- No barefoot running or walking
- Application of local ice
- Reducing running volume significantly
- Taping of the affected toe into plantarflexion every 2-3 days
- Orthotics with a metatarsal pad to reduce the load on the plantar plate
- Avoid thin-soled or slip-on footwear and purchase a rocker-soled pair of trainers such as Asics GlideRide3 or any HOKA set with a forefoot rocker.
After six weeks, gradually increase impact activity and start intrinsic strengthening with taping and orthotics.
After 3-4 months, you can return to regular activity and footwear if tolerated.
Plantar plate surgery
Surgery should only be considered if symptoms are not well-controlled with conservative treatment or if toe deformity, such as a hammer or floating toe, occurs.
Frequently asked questions about plantar plate tears:
How does a plantar plate tear usually present?
In a study examining this question, most cases presented with a gradual onset of pain in the forefoot. Acute and sudden pain was less common.
How long does a torn plantar plate take to heal?
A torn plantar plate can take up to four months to settle. Because of the risk of developing a toe deformity, it is best to avoid too much impact activity during this time.
Can you walk on a plantar plate rupture?
Yes, but we recommend you wear proper supportive shoes such as HOKA, preferably with orthotics and taping.
Is a cortisone injection for plantar plate tear an option?
We don’t recommend a cortisone shot for plantar plate tear. Cortisone weakens the plantar plate and may increase the risk of toe deformity or MTP joint dislocation.
Final word from Sportdoctorlondon about plantar plate tear
Plantar plate tears commonly cause pain in the lesser (2nd-5th) toes. You should see a doctor to get a correct diagnosis and management plan.
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