Plantar Plate Tear

Question 1

anatomy of the region including the plantar plate:

Answer 1

• Aids in stability and prevents hyperextension of the lesser MTPJ
• Fibrocartilaginous plantar plate is formed by distal plantar aponeurosis, lesser MPJ collateral ligaments, deep transverse met ligament, and thickening of lesser MPJ plantar capsule.
• Degeneration, partial tears or rupture of plantar plate result in significant Ffoot pain
• Symptoms include: focal tenderness, oedema to plantar aspect of lesser MPJ w instability of lesser MPJ
• Aetiology: hammertoe deformity, trauma, ill fitting foot wear,

Question 2

role of the plantar plate?

Answer 2

• Protects WB surface of met heads and w collateral ligs contribute to stability of MTPJ- serve as a central stabilizing structure w a fibrocartilaginous composition that allows it to withstand compressive load

Question 3

differential diagnoses for the presenting complaint:

Answer 3

• Metatarsalgia, Morton’s neuroma, tenosynovitis,

Question 4

What further information and tests would you like to undertake for the patient?

Answer 4

• Clinical history and physical examination
  o NOLDCAT
   Nature- what type of pain i.e.burning, numb, tingly
   Onset- when does it hurt, triggers
   Location- where is the pain
   Duration- how long has it. Been there, when did you first notice
   Cause- the HOW-acute event? Insidious?
   Alleviating/ aggravating- what makes it better/ worse?
   Treatment- have you seen anyone else regarding this?
  o Type of footwear- running and general
  o Current occupation- FW
  o FPI- plantar plate tear may occur in pts with pronated foot posture. Lengthening of medial arch causes the plantar fascia to tighten which will cause more pull and strain on plantar plate leading to tear
  o Ankle range (equinas) STJ pronates more to compensate, so midfoot collapse to get more range
  o Lachmans test  AP drawer test  a 2mm or 50% joint displacement is positive sign of plantar plate laxity
  o V sign
  o Floating digit
• Calf raise- single
• Toe walking test ( any pain?)
• Hopping
• Calf raise on exposed met heads
• MRI
• US

Question 5

Short term

Answer 5

• Goals of pt
• Ligament- so poor blood supply- takes longer to heel
• Goal of rx realign digit and provide pressure and pain relief
• NSAIDs- reduce inflammation
• Rest
• Discuss FW educate on what would be good for her (cushioning, rigid sole, rocker) can put carbon fibre plate make it stiffer and stop teo from hyperextending
• Taping: aim of tapping is to position toe in neutral position to provide stability
  o Strap affected toe (2nd) into a downward pos, whilst also correcting any sideward drifting that may be present  allowing for plantar plate to heal
• Offloading using a met pad
  o Placing a met pad proximal to 2nd met hed to redistribute the weight and offload the painful MPJ

Question 6

Long term:

Answer 6

• Activity modification
• Orthotics with metarsal modifications i.e. met dome – realign digit and offload 2nd met head,help with overstraining plantarfascia. And thus dec pull on plantar plate
• Footwear modifications- stiff- soled or rocker shoe that dec. roll-off. Phase of push off
  Excessive pronation leads to muscles of tib post, FHL and FDL to contract eccentrically harder and longer to resist pronation after heel strike.
  Tight hamstrings, gastroc and over pronation resulting in peroneals working harder than tib post at MLA causing overuse