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Plantar Plate Tear

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Other Names

  • Plantar Plate Insufficiency

Background

  • This page refers to injuries to the Plantar Plate of digits 2-5
    • Turf Toe or plantar plate injury of the 1st MTP joint is discussed separately

History

Epidemiology

  • Not well described in the literature

Pathophysiology

  • General
    • The plantar plate is a complex soft tissue structure at the MTPJ of all 5 digits
    • The second toe is most commonly involved, although it can occur in any lesser toe
    • Course may be acute or insidious
    • Early detection is difficult and thus delay in diagnosis is common

Etiology

  • General
    • The cause is likely multifactorial
    • Most often, the product of an insidious and idiopathic onset of patient symptoms from attritional changes
    • Typically difficult to delineate the etiology
  • Acute
  • Chronic, degenerative

Associated Conditions

Pathoanatomy

  • Plantar Plate
    • Primary stabilizer of the MTP joint in the dorsal-plantar direction

Risk Factors

  • Systemic
    • Chronic inflammatory disease (needs to be better delineated)
  • Podiatric
    • Long second metatarsal[2]
    • Hallux Valgus
    • Hallux Varus
    • Hallux Rigidus
    • Hammer toe deformity
    • Pes Planovalgus
  • Other
    • High heeled shoes

Differential Diagnosis

Clinical Features

  • History
    • Patients typically endorse plantar forefoot and submetatarsal pain
    • In one study, 69% of patients reported acute onset of pain (need citation)
    • Klein et al compared preoperative clinical exam and operative findings correlations[2]
      • Gradual onset of pain (93% sensitive)
      • Previous first ray surgery (100% sensitive, despite an incidence of 18%)
      • Edema at the second metatarsal head (95.8% sensitive)
      • Acute onset of pain and toe deformity was rare but specific (7% incidence, 100% specificity)
  • Physical Exam: Physical Exam Foot
    • Dorsal elevation is seen in 93% of plantar plate lesions (need citation)
    • Acquired deformity and MTPJ instability are commonly seen[3]
    • Specifically, the affected toe typically deviates medially, with gapping or splaying of the affected and adjacent toe
    • The toe may appear swollen
    • With disease progression, the affected toe drifts into hyperextension, subsequent subluxation and dislocation leading to a hammertoe deformity
    • Tenderness is maximal at the plantar plate insertion on the proximal phalanx[4]
    • Plantarflexion strength is often diminished
  • Special Tests
    • MTP Drawer Test: stabilize metatarsal, proximal phalanx and attempt to dorsally dislocate proximal phalanx
    • Paper Pull Out Test: place paper below affected toe, plantarflex against ground and attempt to pull out

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Standard weightbearing views should be obtained in all patients
  • Potential findings[2]
    • Disruption in the metatarsal parabola of the symptomatic foot, with an increase in length of the symptomatic metatarsal
    • Increase in the 1—2 intermetatarsal angle with associated hallux valgus
    • Medial deviation of the second toe ands playing of the digits
  • V-sign
    • Widening between the second and third phalanx seen on the AP view

MRI

  • General
    • Specific and reliable in identifying plantar plate tears[5]
  • MRI predictors of plantar plate tear[6]
    • Lesser metatarsal supination > 36 degrees trends towards tear
    • Second metatarsal protrusion > 4 mm trend, > 4.5 mm strong PPD towards plantar plate tear
    • Lesser metatarsal supination < 24 degrees is a strong negative predictor

Ultrasound

  • US vs MRI[7]
    • US is more sensitive than MRI (91.5% versus 73.9%)
    • MRI is more specific (100% versus 25%)

Classification

Clinical Staging System for Lesser MTP Joint Instability

  • Grade 0
    • Alignment: No deformity, no malalignment
    • Physical examination: Pain, swelling of the MTPJ, reduced toe purchase, negative drawer
  • Grade 1
    • Alignment: Mild malalignment, widening of the web space, medial toe deviation
    • Physical examination: Pain, swelling of the MTPJ, loss of toe purchase, mild drawer test
  • Grade 2
    • Alignment: Moderate malalignment, dorsomedial toe subluxation hyperextension of toe
    • Physical examination: Pain, reduction of swelling, no toe purchase, moderate drawer test
  • Grade 3
    • Alignment: Severe malalignment, overlapping toes, flexible hammertoe
    • Physical examination: Pain, little swelling, no toe purchase, dislocatable MTPJ, hammertoe
  • Grade 4
    • Alignment: Severe deformity, Dorsomedial or dorsal toe dislocation, fixed hammertoe
    • Physical examination: Pain, little or no swelling, no toe purchase, dislocated MTPJ, fixed hammertoe

Management

Nonoperative

Examples of conservative treatment options including (A) full length graphite insole with metatarsal pad, (B) toe padding, (C & D) Plantarflexor toe taping[8]
  • Indications
    • Most cases
  • Objective
    • Halt progression of the disease
    • Relieve painful symptoms
  • Shoe modification may alleviate symptoms incuding
    • Wide toe box
    • Reduction of heel height
    • Rigid rocker-bottom sole
    • Full length graphite insole with metatarsal pad
  • Adjuncts which can unload, stabilize joint
    • Plantarflexor toe taping in early stages
    • Metatarsal Pads
    • Toe splints
  • If Hammer Toe Deformity is present
    • Treat, commonly with with toe sleeves or toe pads
  • Medications
  • Corticosteroid Injection
    • Approach with caution as it may weaken the soft tissues, progress instability
    • May also be diagnostic and therapeutic

Operative

  • Indications
    • Failure of conservative therapy
  • Technique
    • Synovectomy
    • Radiofrequency shrinkage (Grade 0, 1)
    • Primary repair (Grade 2, 3)
    • Weil osteotomy combined with a flexor-to-extensor tendon transfer (Grade 4)

Rehab and Return to Play

Rehabilitation

  • Postoperative
    • Requires 4-6 months to mature complete
    • Maintain toe in 20° plantaflexion for 6 weeks
  • Rehabilitation
    • Starts week 1: reduce scarring, strengthen flexor tendon, maintain mobility
    • Avoid passive/ active dorsiflexion for 6 weeks
    • Tape toes in light plantarflex for 3 months
    • For 6 months post op, use low heeled shoes with wide toe box or rocker bottom sole shoe

Return to Play/ Work

  • General
    • High impact sports are avoided for the first year
    • RTP occurs gradually, carefully to protect the surgical repair and prevent reinjury.

Complications and Prognosis

Prognosis

  • Unknown

Complications

See Also

References

  1. ↑ Coughlin MJ, Schenck Jr RC, Shurnas PS, Bloome DM. Concurrent interdigital neuroma and MTP joint instability: long term results of treatment. Foot Ankle Int 2002;23(11):1018—25.
  2. ↑ 2.0 2.1 2.2 Fleischer AE, Klein EE, Ahmad M, Shah S, Catena F, WeilL SSr, et al. Association of abnormal metatarsal parabola with second metatarsophalangeal joint plantar plate pathology. Foot Ankle Int 2017;38(3):289—97.
  3. ↑ Smith BW, Coughlin MJ. Disorders of the lesser toes. Sports Med Arthrosc Rev 2009;17(3):167–174
  4. ↑ Nery C, Coughlin MJ, Baumfeld D, Raduan FC, Mann TS, Catena F. Classification of metatarsophalangeal joint plantar plate injuries: history and physical examination variables. J Surg Orthop Adv 2014;23(4):214–223
  5. ↑ Sung W, Weil L Jr, Weil L SSr, Rolfes RJ. Diagnosis of plantar plate injury by magnetic resonance imaging with reference to intraoperative findings. J Foot Ankle Surg2012;51(5):570—4.
  6. ↑ Umans R, Umans B, Umans H, Elsinger E. Predictive MRI correlates of lesser metatarsophalangeal joint (MPJ) plantar plate (PP) tear. Skeletal Radiology 2016 DOI 10.1007/s00256-016-2375-x
  7. ↑ Klein EE, Weil L Jr, Weil L S Sr, Knight J. Magnetic resonance imaging versus musculoskeletal ultrasound for identification and localization of plantar plate tears. Foot Ankle Spec 2012;5(6):359—65.
  8. ↑ Jastifer, James R., Jesse Doty, and Leif Claassen. "Current concepts in the treatment of metatarsophalangeal joint instability of the lesser toes: review, surgical technique, and early outcomes." Fuß & Sprunggelenk 15.4 (2017): 225-236.
Created by:
John Kiel on 31 January 2022 05:08:02
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Last edited:
4 October 2022 12:40:37
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