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Plantar Plate Tear

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Other Names

  • Plantar Plate Insufficiency


  • 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



  • Not well described in the literature


  • 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


  • 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


  • 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



  • 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


  • 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


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


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



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


  • 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


  • 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


  • Unknown


See Also


  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
Last edited:
4 October 2022 12:40:37