A plantar plate tear is a common injury of the foot, specifically at the junction of the toes. The plantar plate is a strong ligament that runs across the bottom of the foot, holding the toes in place and providing support for the ball of the foot. A plantar plate tear or sprain occurs when the ligament on the bottom of the foot is torn, causing foot pain that makes it even more painful to walk for runs or to engage in other activities. Understanding the causes, symptoms, and treatment options for this condition is essential.
Teers of the plantar plate are commonly caused by overuse, with high-impact activities such as distance running and jumping sports placing the highest risk on the foot. Other activities, such as basketball and soccer, may also cause the foot to suffer from a torn plantar plate. Teers of the plantar plate can also be caused by the use of inappropriate footwear, such as shoes that are not the correct size, high-heeled shoes and narrow toed shoes. Additionally, athletes may increase their risk of experiencing a torn plantar plate by wearing inappropriate footwear for the specific sport or activity in which they are participating.
While overuse and choice of footwear are common causes of plantar plate tears, trauma can also cause a tear. For example, a plantar plate tear could be caused by a fall onto the ground from a height. Certain factors increase a person’s risk of developing a plantar plate injury. People who participate in high-impact activities, such as running or dancing, may be more likely to experience a plantar plate tear. People with pre-existing foot deformities, such as bunions or flat feet, are also more susceptible to a plantar plate injury due to the abnormal stress put on different parts of the foot.
As with many common podiatric problems, it is essential that you understand the causes and risk factors of plantar plate tears to recognize the potential consequences of inaction. If left untreated, plantar plate tears can become a source of chronic pain, impacting your ability to participate in activities you love. The constant stress on your feet can cause you to alter your gait, leading to dysfunction of other areas of your foot and lower extremity, adding to your overall discomfort.
What appears to be a minor injury at first, plant plate tears can have serious and long lasting implications for people who have them. It is very important that you are aware of the signs and symptoms and seek the advice of a specialist as early as possible. Symptoms of a plantar plate tear can significantly affect a person’s daily activities. The most common symptoms are pain in the forefoot, usually under the metatarsal bones (the long bones in the middle of the foot). The pain can feel sharp or aching and usually gets worse when standing or walking. Swelling can occur in the foot and the pain can get worse when running or performing athletic activities. In some cases the swelling can force people to avoid wearing shoes due to discomfort. Swelling also is a sign of ongoing inflammation.
Tendon pain around the ball of the foot, change in gait, and difficulty performing physical activities are symptoms of plantar plate tears. Many sufferers of this condition will find that sports and other activities will no longer be enjoyable due to the pain felt. You may also find that tasks such as shopping may become more difficult if you have to push off the toe or stand on the ball of the foot, two common positions that can cause pain to individuals with this condition. As a result, many people tend to be less active, which can decrease overall fitness level.
In order to treat individuals with symptoms of a plantar plate tear, it is essential that a thorough clinical assessment be carried out to diagnose the condition. Initial physical assessment of the foot will evaluate for tenderness and swelling and also assess mobility of the foot. Further diagnostic imaging such as X-ray or MRI may also be required to clearly see the soft tissues and confirm the diagnosis. Once a correct diagnosis has been established, the health care professional can prescribe the correct treatment to ensure no further damage occurs to the foot.
While generally not severely painful, some plantar plate tears can cause quite distressing symptoms. Patients who have suffered from a tear on the bottom of their foot often walk abnormally putting pressure on other parts of the foot to avoid the painful area. Over time this can place unusual stress on other areas of the body, putting the knees, hips and lower back at risk. As found by Nery, Linklater & Bird (2015, 2016), individuals who have pain on the bottom of the foot change the way they walk in an attempt to avoid loading the painful area. However, in attempting to avoid pain in one part of the foot, individuals create muscle imbalances in the foot and elsewhere which can result in long term pain and potentially require surgery.
Being unable to walk or participate in activities of daily living can have further significant psychological and emotional effects. Painful feet can be very distressing; many people feel frustrated, and can become helpless or depressed, becoming less motivated and withdrawing from social life. Such symptoms can threaten the quality of life, and it is essential to treat them early to prevent long-term disability, pain, and impairment of function. However, treatment for plantar plate tears often includes both conservative management (without surgical intervention) and surgical methods, and the choice of treatment depends on the severity of the tear and whether the symptoms are affecting normal activities.
Conservative management is typically the initial course of treatment for plantar fasciitis. This begins with the use of orthotics, specifically shoe inserts that act as supportive devices to cushion the heel and redistribute weight to prevent over-pronation or stress on the plantar fascia. Patients may benefit from both over-the-counter and custom orthotics, depending on the specific structure of the foot. In addition to supportive devices, physical therapy is critical in the treatment of plantar fasciitis. A physical therapist can design a series of exercises intended to strengthen the muscles surrounding the foot, improve flexibility, correct abnormal gait or biomechanics that may be placing additional stress on the plantar fascia, and enhance balance and overall physical activity to prevent future injury.
It is common place these days for many conservative treatments to be used to manage painful foot conditions. The majority of patients with a plantar plate injury treated with splinting, orthotics, pain relief and physical exercises will improve significantly with treatment and return to activity (Flint et al., 2017; Elmajee et al., 2017). However, there are some cases where surgical intervention will be required such as in severe tears of the plantar plate or if the above treatments fail to provide relief after several months.
Surgical treatment aims to treat the torn plantar part and any associated deformity of the foot. The evidence suggests that surgery is very effective in treating pain due to a torn plantar plate and enabling the patient to walk pain free. Most importantly, early intervention gives the best chance of regaining maximal function. Delaying surgery could result in permanent disability and lead to chronic pain.
Management of plantar plate tears is important to prevent long term complications. Neglect or poor management of plantar plate tears can cause ongoing pain and impaired mobility, leading to a permanent gait abnormality and causing increased stress on other areas of the foot. This can potentially lead to further injury or other foot conditions. Secondary complications such as metatarsalgia, stress fractures or arthritis of the joints of the foot can also occur (Nery et al., 2014).
Appropriate management of plantar plate injuries prevents long-term complications such as persistent pain and disability. Management of plantar plate injury should therefore start with conservative measures, with surgical intervention indicated only when necessary. By treating the symptoms of a plantar plate tear effectively, patients can return to normal activities of daily living, maintain foot function and mobility. (Jha & Clark, 2023).
Citations:
Nery, C., Coughlin, M.J., Baumfeld, D., Raduan, F.C., Mann, T.S. and Catena, F., 2014. Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears. Foot & Ankle International, 35(9), pp.876-885. https://journals.sagepub.com/doi/abs/10.1177/1071100714539659
Nery, C., Umans, H. and Baumfeld, D., 2016, April. Etiology, clinical assessment, and surgical repair of plantar plate tears. In Seminars in musculoskeletal radiology (Vol. 20, No. 02, pp. 205-213). Thieme Medical Publishers. https://www.thieme-connect.com/products/all/doi/10.1055/s-0036-1581114
Klein, E.E., Weil Jr, L., Weil Sr, L.S., Coughlin, M.J. and Knight, J., 2013. Clinical examination of plantar plate abnormality: a diagnostic perspective. Foot & Ankle International, 34(6), pp.800-804. https://journals.sagepub.com/doi/abs/10.1177/1071100712471825
Jha, S. and Clark, C., 2023. Plantar plate rupture: aetiology, diagnosis and treatment. Orthopaedics and Trauma, 37(1), pp.28-33. https://www.sciencedirect.com/science/article/pii/S1877132722001245
Nery, C., Coughlin, M., Baumfeld, D., Raduan, F., Mann, T.S. and Catena, F., 2015. How to classify plantar plate injuries: parameters from history and physical examination. Revista Brasileira de Ortopedia (English Edition), 50(6), pp.720-728. https://www.sciencedirect.com/science/article/pii/S2255497115001512
Linklater, J.M. and Bird, S.J., 2016, April. Imaging of lesser metatarsophalangeal joint plantar plate degeneration, tear, and repair. In Seminars in Musculoskeletal Radiology (Vol. 20, No. 02, pp. 192-204). Thieme Medical Publishers. https://www.thieme-connect.com/products/all/doi/10.1055/s-0036-1581115
Nery, C., Coughlin, M.J., Baumfeld, D. and Mann, T.S., 2012. Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. Foot & Ankle International, 33(4), pp.301-311. https://journals.sagepub.com/doi/abs/10.3113/fai.2012.0301
McCarthy, C.L. and Thompson, G.V., 2021. Ultrasound findings of plantar plate tears of the lesser metatarsophalangeal joints. Skeletal Radiology, 50(8), pp.1513-1525. https://link.springer.com/article/10.1007/s00256-020-03708-1
Flint, W.W., Macias, D.M., Jastifer, J.R., Doty, J.F., Hirose, C.B. and Coughlin, M.J., 2017. Plantar plate repair for lesser metatarsophalangeal joint instability. Foot & ankle international, 38(3), pp.234-242. https://journals.sagepub.com/doi/abs/10.1177/1071100716679110
Elmajee, M., Shen, Z., A’Court, J. and Pillai, A., 2017. A systematic review of plantar plate repair in the management of lesser metatarsophalangeal joint instability. The Journal of Foot and Ankle Surgery, 56(6), pp.1244-1248. https://www.sciencedirect.com/science/article/pii/S1067251617303563
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