Planter Plate Tears of the Lesser Toes
Introduction
The plantar plate is a type I collagen ligamentous structure that supports the plantar aspect of the metatarsophalangeal joint (1). The plantar plate resists loads that occur with dorsiflexion of the toes and also help to cushion and support the MTP joint (3). An intact plantar plate is necessary to ensure the proximal phalanx does not sublux from the joint and to avoid the development of pain or rigid hammertoe deformity (2). Injuries to the plantar plate can be both acute and chronic (5).
Anatomy of the plantar plate (5)
Diagnosis
Diagnosis of a plantar plate is considered when a patient complains of forefoot pain. The differential for forefoot pain includes a Morton’s Neuroma, stress fracture, Freiberg infraction, and capsular degeneration (3). Clinical evaluation will identify a swollen MTP capsule, a floating toe, or a medially displaced toe (1). Gapping between the toes indicates a plantar plate tear and usually occurs in a medial direction (2). Physical examination should also include a drawer test to assess for joint laxity (3). A Mulder’s maneuver should also be done to rule out a Morton’s neuroma (4). A paper pull-out test can also be done to assess for any weakness with plantarflexion, which can be seen with a plantar plate tear (6).
Proximal phalanx drawer test (6)
First line imaging includes an AP, lateral, and oblique radiograph (4). Radiographs can evaluate for toe gapping or MTP joint subluxation (4). Widening between the second and third phalanx, seen on the AP x-ray, is called a V-sign (7). An ultrasound evaluation of the MTP joint can also be used to identify tears within the plantar plate (5). An MRI is used to diagnose a plantar plate tear (2). Tears can be identified by increased T2 signal on the coronal and sagittal images of the forefoot (2). There is a high sensitivity over 90% when diagnosing a plantar plate tear with an MRI (2). The plantar plate tear typically occurs at the insertion on the proximal phalanx (7).
Plantar plate tear on MRI. Short arrow is flexor tendon and long arrow is a partial plantar plate tear (2)
Treatment
Nonsurgical treatment typically aims at halting the progression of the plantar plate tear (3). Conservative measures include avoiding heels, wearing a wide toe box, and using a rigid rocker bottom sole (3). Patients can also try plantarflexion toe taping, wearing a carbon insert, metatarsal pads, and toe splints to help with symptoms (3). Corticosteroid injections into the MTP joint can help with pain, but can further weaken the plantar plate (6). Multiple surgical options exist and have exhibited good clinical outcomes (3). There is no gold standard surgical treatment for plantar plate tears (4).
Conclusion
Plantar plate tears can be an acute or chronic process. Providers should consider plantar plate tears in any cases of forefoot pain. Both physical exam and imaging can aid in diagnosis. Ultimately, surgery is sometimes required to repair the damaged plantar plate.
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References
1) Klein, Erin E., et al. “Clinical Examination of Plantar Plate Abnormality: A Diagnostic Perspective.” Foot & Ankle International, vol. 34, no. 6, June 2013, pp. 800–04. PubMed, https://doi.org/10.1177/1071100712471825.
2) Sung, Wenjay, et al. “Diagnosis of Plantar Plate Injury by Magnetic Resonance Imaging with Reference to Intraoperative Findings.” The Journal of Foot and Ankle Surgery: Official Publication of the American College of Foot and Ankle Surgeons, vol. 51, no. 5, Oct. 2012, pp. 570–74. PubMed, https://doi.org/10.1053/j.jfas.2012.05.009.
3) Nery, Caio, et al. “Etiology, Clinical Assessment, and Surgical Repair of Plantar Plate Tears.” Seminars in Musculoskeletal Radiology, vol. 20, no. 2, Apr. 2016, pp. 205–13. PubMed, https://doi.org/10.1055/s-0036-1581114.
4) Nery, Caio, and Daniel Baumfeld. “Lesser Metatarsophalangeal Joint Instability: Treatment with Tendon Transfers.” Foot and Ankle Clinics, vol. 23, no. 1, Mar. 2018, pp. 103–26. PubMed, https://doi.org/10.1016/j.fcl.2017.09.008.
5) McCarthy, Catherine L., and Graeme V. Thompson. “Ultrasound Findings of Plantar Plate Tears of the Lesser Metatarsophalangeal Joints.” Skeletal Radiology, vol. 50, no. 8, Aug. 2021, pp. 1513–25. PubMed, https://doi.org/10.1007/s00256-020-03708-1.
6) Doty, Jesse F., and Michael J. Coughlin. “Metatarsophalangeal Joint Instability of the Lesser Toes and Plantar Plate Deficiency.” The Journal of the American Academy of Orthopaedic Surgeons, vol. 22, no. 4, Apr. 2014, pp. 235–45. PubMed, https://doi.org/10.5435/JAAOS-22-04-235
7) Akoh, Craig C., and Phinit Phisitkul. “Plantar Plate Injury and Angular Toe Deformity.” Foot and Ankle Clinics, vol. 23, no. 4, Dec. 2018, pp. 703–13. PubMed, https://doi.org/10.1016/j.fcl.2018.07.010.
By Gregory Rubin, DO
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