What is the plantar plate?
The plantar plate is a ligamentous structure which lies beneath the metatarsophalangeal joints of the lesser toes. This structure helps support and stabilise these joints during walking and activity.
What is a plantar plate injury/ tear?
A plantar plate injury occurs when there is disruption to the ligament structure which can be mild, moderate or can lead to complete rupture of the plantar plate.
- In mild cases, there may be some joint swelling and loss of toe grip.
- In moderate cases, there may be some mild laxity in the toe joint.
- In severe cases, there may be instability within the joint and can lead to a crossover toe deformity where the toe will deviate to lie over the adjacent toe.
This injury occurs most commonly in the second toe joint but can also occur within the third, fourth and fifth joints. Injuries can be:
- chronic – in which they develop slowly over time
- acute – where there is a sudden injury
Plantar plate injury is seen as a common problem of the forefoot. There is a higher incidence of plantar plate injuries in women in comparison to men at a ratio of 10:1. Injury is more common over the age of 50 years.
Causes
There are a number of risk factors for developing a plantar plate injury;
- Age – these injuries are most common in the over 50s.
- Gender – it is more common in females.
- Weight – if you have a higher than average BMI you are more at risk.
- Strength – poor strength within the core foot muscles and lower limb.
- Footwear – soft, flexible soled footwear provide little support in the forefoot which can increase the stresses going through the small joints of the foot. Wearing footwear with a high heel also increases the stress on these tissues.
- Altered foot function – The presence of existing foot deformities such as hallux valgus (bunions), a long second toe, flat feet or joint laxity within the joints of the foot can all lead to overloading within these joints.
- Inflammatory arthritis – Many inflammatory joint diseases (for example rheumatoid or psoriatic arthritis) affect the small joints in the foot making them more vulnerable to this condition.
- Sporting activities – certain sporting activities increase the load on these small joints such as running and jumping.
- Occupation – certain occupations may lead to greater strain on these joints.
Symptoms
The most common symptoms that people complain of if they experience a plantar plate injury are:
- Pain in the ball of the foot under the metatarsal head. Patients describe the feeling of walking on a stone or marble.
- Deformity of the toe with either clawing or splaying of the toe. In the later stage of the injury the toe may cross over the next toe.
- Rubbing of the top of the toe from footwear.
- Pain and swelling of the toe joint due to joint inflammation.
- Hard skin may develop on the ball of the foot.
- Reduced strength within the affected toe.
How long will it take to get better?
There are no quick fixes for a plantar plate injury as ligament injuries within the foot can take 3-6 months to heal. However with exercises and lifestyle changes you may see improvements in your pain and walking earlier and help prevent a deterioration of your injury.
What can I do to help my plantar plate injury?
Treatment is aimed at reducing the stress or load through the affected joint to allow the ligaments to heal and improving strength around the affected joint. Changes in lifestyle can also be helpful to aid in your recovery.
The one person who can help you manage your symptoms is you.
Footwear
One of the most important changes you can make is to your footwear.
- Avoid walking in bare feet until your pain has resolved
- Avoid high heeled shoes or shoes with a flexible sole as these place increased stress on the joints of the forefoot.
- Avoid shoes which cause you to claw your toes such as flip flops / mules / crocs.
Look for a shoe that has the following qualities;
- Heels should be broad and no more than 1.5 inches high.
- Soles should be firm and non-pliable.
- Deep fitting footwear will provide plenty of room for your toes and accommodate any potential toe deformity.
- Lacing or Velcro straps to hold the shoe firmly to the foot. E.g. running or walking shoe
- A rocker at the forefoot can limit bending of the joint during gait and therefore reduce pain – see picture below. See our footwear advice video or our footwear advice section for further guidance.
Strapping
Strapping of the affected toe can reduce pressure and pain levels and aid the healing process.
Strapping can be in the form of:
- self applied tape
- purchasing an over the counter device to hold your toe in place
Strapping is recommended for a period of 4 to 6 weeks following your injury or until your symptoms subside.
Self-applied taping
To tape your toes, please follow these steps:
- Ideally, you need a length of tape measuring approximately 8-9 cm long and 1 cm wide.
- The tape should be threaded between the toes, placed over the base of the affected toe and again threaded between the toes on the opposite side.
- The toe should be brought down to align with the rest of the toes. It is important not to bring the toe down too far or apply the tape too tightly, that it impairs the circulation.
- The two lengths of tape are crossed over in to a ‘V’ shape under the ball of the foot.
- Further strips of tape are used to secure the strapping to the ball of the foot. Ideally this strapping should be replaced every 2-3 days.
Strengthening and Stretching Exercises
Targeted strengthening and stretching exercises for the muscles in and around your foot and ankle can help to improve your symptoms. Local NHS Ayrshire & Arran podiatrists have devised exercise videos to help with strengthening the correct muscles.
Ice
Icing can be beneficial in the first 2 to 3 days following injury or to help manage any flare ups of pain.
Some people do find continual benefit of regularly icing for several weeks following the injury.
Weight Management
If you have a higher than average body mass index (BMI) you are more at risk. See our weight management section for further guidance.
Foot orthoses
Foot orthoses may be considered if self-management and exercises have not improved your symptoms.
Your local MSK podiatrist may prescribe some foot orthoses to wear in your shoes to try and offload the joint. Relief can be felt from a stiff, firm insole or one which provides a metatarsal support at the painful joint.
Investigations and surgery
Do I need a scan?
A plantar plate injury is usually diagnosed primarily via a physical examination and patient history.
Your clinician will put stress on the ligament and joint to test its integrity. X-rays and additional imaging tests such as diagnostic ultrasound scans can also be used to confirm a plantar plate injury, if required.
Will I need surgery?
Surgical management is not usually considered unless your injury is severe or you have tried all of the above measures and continue to have difficulty walking.
If all non surgical treatment has failed or you have developed a fixed toe deformity then it may be appropriate for a referral to an orthopaedic surgeon to consider a surgical intervention.