Plantar Plate Injuries

Kim Tottenham

Podiatrist

Exercise is Medicine

• Physical inactivity is a major health

problem

• Keep people moving.

Plantar Plate Injuries

• Anatomy

• Mechanism of injury

• Assessment and clinical tests

• Diagnosis and differential dx

• Imaging

• Conservative treatment options.

Plantar Plate Function

• Fibrocartilaginous

structure

• Acts as an attachment for

PF

• Stabilising digits

• Reduces compressive

loads on met heads

• Role in windlass action

• Helps with the line of pull

of the lumbricals and

FDL.

Anatomy 3 points regarding injuries:

1. Differences at origin & insertion

2. Avascular nature

3. Length of metatarsals – vulnerability

(acknowledgement for Ted Jedynak, 2015)

Plantar Plate Injuries

tarsal

Assessment

Signs and Symptoms:

• Focal pain distal to MTPJ’s

• Hx of trauma/tripping

• c/o “lump” or “bruised feeling”

• Notice gradual hammering of

digit

• Associated hallux valgus

• Forefoot in prolonged

dorsiflexion.

• Callus formation if chronic.

Mechanism of Injury:

• Excessive load on MTPJ while

in dorsiflexion.

• Progressive overload eg 1st

MTPJ arthritis, HAV, short 1st

met, long 2nd, abnormal bmx

overloading mets, steroid

injection, acute trauma.

• What is the patient telling you:

– “I’m a rugby prop/ a ballroom

dancer/do lots of gardening...”

Diagnosis

Assessment:

• Patient history

• Appearance of digit

Clinical tests:

1. Direct pressure

2. P/F prox phalange

3. Positive vertical stress test (hold

met head and elevate proximal

digit) 2mm translocation

suggestive of rupture.

• Stress #

• Flexor tendinopathy

• Capsulitis

• Hammer toe deformity

• Degenerative jnt disease

• Avascular necrosis

• Synovitis

• Neuroma/IM bursitis.

Differential Dx:

Imaging

X-ray always WB, DP and lateral

Shows subluxation/dislocation

Ultrasound is helpful, dynamic

Differential dx:

• Tear

• Rupture

• Neuroma/IM bursitis.

1. Sonographer can stress the tissues in different directions, to identify where the breakdown of the plantar plate lies.

2. Colour doppler is useful can detect blood flow.

3. Useful if there is a cortisone injection for guidance. (Not recommended).

Treatment

Aim: realignment of digit/pl plate.

Facilitate “toe purchase”. Prevent or

slow progressive deformity. Cushion

painful MTPJ’s. Reduce pain.

•Strapping/taping (6-12 weeks) , esp if

no deformity.

•Rest from aggravating factors.

•Orthotics/padding to realign digit.

Aim to provide a dorsiflexory force to

the metatarsals while allowing plantar

flexion of digits. Improves the

apposition of torn ligament tissues.

•Shoes with a rocker bottom.

•Avoid U-shaped design (p/f of met)

can worsen the hammering of the

digit.

•Immobilisation

•Physical Therapy - self mobilise

dorsal extensor tissues - exercises

•NSAID’s

•Corticosteroids oral

–No injections (weakens connective

tissues/small risk of sepsis)

•Surgery.

Three Key Elements for

Successful Treatment

1. Clear communication

2. Remove tissue stress

3. Dorsal extensor releases.

(Acknowledgement to Ted Jedynak, educator)

Forefoot Pain