Hi. I'm Dr. Hale. Today, we're going to talk about treatment for plantar plate injuries.
We typically suspect a plantar plate injury when your toe elevates, especially your second toe.
The plantar plate is a strong ligament-type structure on the bottom of your toe joint,
keeping your toe down straight and fluid in your joint. Plantar plate tear can
be acute or chronic. This is important because onset determines treatment.
In both acute and chronic conditions, your doctor will notice instability of the joint.
The gold standard for diagnosis is made by injecting your joint with dye.
Usually, you'll notice fluid going out the bottom of the joint. Acute onset is usually associated
with trauma. You'll notice pain and swelling, typically region of the second toe joint, which
we call the second metatarsal joint, and elevation of your toe. For an acute tear it is important to
immediately start taping your toe down and offload your joint. We first offload the joint with a
below-knee walking boot with an accommodation for the joint, and then work you into an insole
and rockered soled shoe to continue offloading the joint. Remember to continue taping the toe down to
allow the plantar plate to heal. A large acute tear may require early surgical intervention.
Surgery for most acute tears is through the bottom of your foot. If you have a long second metatarsal
contributing to joint overload, your doctor may choose to go through the top of the joint.
Chronic repetitive forces to joint may gradually cause the ligament to tear, also resulting in
elevation of the toe and pain. For chronic plantar plate tears we suggest exhausting
all conservative options prior to considering surgery. For both chronic and acute tears,
we use shoes with a forefoot rocker to offload the joint. It's important to have an over-the-counter
insole or custom orthotic that transfers weight into the arch and off the painful joint.
The orthotic must have a hole or a slot under the joint to reduce pressure. It is important
your doctor knows how to properly offload the joint with an orthotic. For information
on supportive over-the-counter insoles, or total contact orthotics, go to our website. You can also
use an over-the-counter device such as a Budin Splint, or Digit Wrap to hold your toe down.
For a surgical correction, your surgeon has the option of going through the top or bottom
of your foot. For both approaches, the goal is to simply suture a tear in the plantar plate closed.
For the bottom approach it is important your surgeon not place incision over the metatarsal
head or you may have a painful scar. The advantage of the plantar approach is it
does not require a shortening of the metatarsal. The top approach requires cutting, shortening,
and fixation of the metatarsal in order to access the plantar plate. Whatever the condition may be
due to a long metatarsal, so shortening of the bone may be necessary. A variety manufacturers
make instrumentation for plantar plate repairs through the top of your foot. We do not suggest
any procedures that use instrumentation that tear off the plantar plate from the metatarsal head.
The chronic plantar plate tear causes the toe to elevate and the metatarsal head to protrude
through the plantar plate. This can sometimes be fixed with a flexor tendon transfer.
The flexor transfer straightens the toe and pulls the metatarsal head upwards.
This may be performed with or without a plantar plate repair. Overall conservative options for
acute and chronic plantar plate injuries include temporary use of a below-knee boot, shoes with
a forefoot rocker, insoles to offload the joint, taping and over-the-counter toe splints. Surgery
may be performed through the top or bottom of the foot. Top approach requires cutting and fixation
of the bone. For chronic conditions a flexor tendon transfer may be utilized to pull the toe
down and reduce force off the plantar plate. If you have any further questions about
this condition, or any other foot and ankle condition, go to our website, footankle.com.
If you're interested in shoes that may help your foot condition, you can obtain our shoe list by
going to our main page, scroll to the bottom, and enter your email address. Thanks for watching.