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Dr. Baravarian discusses plantar plate injuries, their causes, the symptoms, and the treatment options.
What's the plantar plate?
The plantar plate is a strong ligament on the bottom of the foot. It is a fibrous structure that connects the base of your toe (proximal phalanx) to the forefoot bone (metatarsal head). The plantar plate runs through the joint capsule within the forefoot. Each of your toes, from the big toe to the pinky, has a plantar plate.
Plantar plates keep the toes in position and prevent them from over-extending or drifting. As stabilizers for the metatarsophalangeal joints, plantar plates serve as attachment points for the plantar fascia and other ligaments and tendons.
A plantar plate tear or injury, sometimes called pre-dislocation syndrome, might be more common than you think, and you may have even experienced one. Since a common sign of a plantar plate injury is the second or third toe crossing over its neighbor, these injuries are also known as “crossover toe deformities.”
What causes plantar plate tears?
The most common cause of plantar plate tears is excessive pressure on the associated metatarsophalangeal joint. This puts strain on the plantar plate and can eventually lead to a tear, causing joint instability and pain.
While sudden plantar plate tears aren’t impossible, they usually develop slowly over time from ongoing strain. Repetitive overuse or foot abnormalities can cause progressive degeneration of the ligament.
The most common causes of plantar plate injuries include:
- Biomechanical abnormalities: A short or elevated first metatarsal and a long second metatarsal can put constant pressure on the plantar plate and contribute to its degeneration.
- Bunions (hallux valgus): Pressure on the toes from a bunion can also increase pressure on the plantar plate, leading to thinning and tearing.
- Cortisone injections: Overuse of cortisone can occasionally cause weakening and thinning of the plantar plate ligament.
What are the symptoms of a plantar plate injury?
Plantar plate injury symptoms can range from mild to severe. They may flare up during physical activity or cause ongoing discomfort even at rest. Symptoms can include:
Pain and Swelling
Plantar plate injuries are a common cause of metatarsalgia (forefoot pain). You may feel a dull ache or sharp pain in the ball of the foot, and it may feel as though there is not enough cushion between the bone and the ground.
Discomfort can increase during dorsiflexion of the foot, which occurs when walking or running. Weakening of the plantar plate in the lesser toes may cause a gradual increase in pain, while those in the big toe can cause severe ball of foot pain and swelling.
Shifting of the toe
As the tear increases, the affected toe (most commonly the second or third toe) shifts upwards or to one side. The second toe moving towards the big toe is particularly common in cases of plantar plate tears. When the foot is placed on the ground, the toe may lift or appear bent.
Chronic Plantar Plate Injury
If not treated correctly, plantar plate tears become chronic, increasing the likelihood of long-term deformity. As the deformity progresses, the cartilage in the joint capsule can become eroded, leading to arthritis and more severe pain.
Diagnosing a plantar plate tear
Dr. Baravarian starts the diagnostic process by reviewing your medical history and symptoms. We will also conduct a physical exam of the affected foot, checking for any limitations or pain during flexion.
To confirm a plantar plate injury (and rule out other possible causes of foot pain), Dr. Baravarian turns to radiographs. Weight-bearing X-rays specifically are very useful for measuring the degree of the injury and formulating a treatment plan.
There is also access to magnetic resonance imaging (MRI) to view the status of your foot ligaments.
Conservative treatments for plantar plate injuries
Dr. Baravarian, opts for conservative treatment whenever possible. When caught in the early stages, conservative treatment of the plantar plate can be highly successful.
Dr. Baravarian’s conservative options may include:
- Pain management: Over-the-counter anti-inflammatory pain medication can keep you comfortable while your plantar plate heals. Icing the area for short periods throughout the day can also help reduce swelling and alleviate pain.
- Support the joint: Taping or strapping the affected joint is useful for holding the joint in place, reducing stretching, and allowing the ligament to heal. Dr. Baravarian sometimes uses stiff-soled shoes or splints to limit mobility further and support the affected area.
- Orthotics: Supportive shoe inserts can also provide support to the ball of the foot, take pressure off, and prevent re-injury.
If your toe has drifted significantly, it indicates that the ligaments around it have stretched. Conservative treatments might relieve the pain, but surgical correction is needed to restore the toe to its proper position.
Plantar plate repair surgical intervention techniques
While it’s important to exhaust all conservative treatment options first, if surgery becomes necessary, Dr. Baravarian is trained in the most current plantar plate surgical techniques.
Dr. Bob's patient Kathy discusses her plantar plate repair surgery and how it significantly improved her quality of life.
The HAT-TRICK procedure
Dr. Baravarian collaborated directly with manufacturers and scientists to develop a product that has revolutionized plantar plate repair: the HAT-TRICK.
Because plantar plate tear surgery rarely involves operating only on the plantar plate, the HAT-TRICK procedure combines three systems that work together to heal your foot. The HAT-TRICK joint repair system is a minimally invasive method for repairing the metatarsophalangeal joint to restore lost joint stability.
When hammertoes or claw toes result from your plantar plate injury, the HAT-TRICK proximal interphalangeal joint fusion system provides a non-invasive implant to straighten your toes.
HAT-TRICK’s third system (the osteotomy guide) shortens the metatarsal bone and can restore your full range of motion. It also provides an improvement over the current standard of care, the Weil Osteotomy.
Complete plantar plate repair system (Arthrex CPR)
The Arthrex CPR system is a specialized device designed to correct a plantar plate rupture and dislocation of the metatarsophalangeal joint. The Arthrex CPR System directly repairs the plantar plate, reducing the risk of recurrence.
Which is better, the Arthrex CPR or HAT-TRICK procedure?
Although the Arthrex CPR is easier for many surgeons to use, several benefits make the HAT-TRICK MTP Joint Repair System a better choice, including:
- Arthrex CPR is only for plantar plate issues, whereas HAT-TRICK allows for the repair of the plantar plate and adjacent ligaments.
- The HAT-TRICK offers a better grip on the plantar plate.
- The Peek implant of the HAT-TRICK allows sutures to be tensioned and tied into the bone, whereas Arthrex CPR does not.
- For increased accuracy, the HAT-TRICK offers an osteotomy guide for the metatarsal, whereas Arthrex CPR does not.
- The HAT-TRICK is a more stable system, allowing you to start physical therapy earlier, leading to a faster recovery.
What is the recovery time for plantar plate surgery?
The recovery period after direct repair of the plantar plate can last four to eight weeks. The plantar plate is a very strong ligament, and it requires time with decreased activity to heal. However, once healed, you will be pain-free!
During recovery from a plantar plate tear surgery, you need to avoid putting weight on your foot, and crutches are often recommended. Depending on the extent of the surgical repair, you may be fitted with a removable boot or a cast.
How to prevent plantar plate tears
Treating chronic plantar plate tears is much harder than preventing them. Patients who recognize the symptoms of a plantar plate injury and get evaluated by Dr. Bob receive the best treatment quickly, which helps avoid more complex procedures.
If you start early and know your risks, you can protect your feet from plantar plate injuries by doing the following:
Custom orthotics
Patients with certain biomechanical factors that increase pressure on the forefoot—such as a long second metatarsal, an elevated first metatarsal, or a short first metatarsal—should wear an orthotic to distribute pressure away from the affected area.
Athletes and runners should also have their feet evaluated by a specialist, such as Dr. Baravarian, to determine if they are placing an additional load on the forefoot.
Proper shoes
Certain shoes can increase pressure on the forefoot. Many running shoes feature a rocker forefoot that helps offload pressure from the ball of the foot. Shoes that are overly flexible may add extra pressure to the forefoot, raising the risk of a plantar plate tear.
Avoid steroid injections into the joint
Many patients often want a quick fix and opt for a joint injection when the tissue is irritated. Although steroid injections can help manage pain, they can weaken soft tissue structures, including the plantar plate. Therefore, steroid injections should be avoided in the lesser toe joints whenever possible.
Accurate diagnosis of a plantar plate tear is critical
Plantar plate injuries are often misdiagnosed as hammertoes, neuromas, or capsulitis (inflammation of the tendons that surround the toe joints). A misdiagnosis means the underlying condition isn’t treated, and the pain and deformity will continue to worsen.
Dr. Baravarian offers the most advanced procedures to treat your plantar plate injury.
When you choose Dr. Baravarian, you can be confident that you are selecting a compassionate specialist with decades of experience. He employs advanced equipment to provide the latest diagnostics, including on-site imaging with an open MRI for the foot and ankle and a weight-bearing 3D CT scan.
While Dr. Bob always exhausts conservative treatment options for plantar plate tears first, if surgery becomes necessary, you will be in the best hands. Dr. Baravarian’s top-notch curative treatments, like the HAT-TRICK™ and the Arthrex Complete Plantar Plate Repair System (CPR™), boast some of the highest success rates in the nation.
Dr. Bob Baravarian has convenient locations throughout Southern California and the Los Angeles area, with offices in or near Santa Monica, Sherman Oaks, Beverly Hills, West Los Angeles, the San Fernando Valley, El Segundo, the South Bay, LAX, Calabasas, Agoura Hills, and Downtown Los Angeles.
Frequently Asked Questions about Plantar Plate Tears and Plantar Plate Surgery
Can a plantar plate tear heal on its own?
A plantar plate tear, an injury to the ligament on the ball of the foot beneath the toe joints, can sometimes heal on its own, especially if it is a minor tear. However, the healing process usually requires specific measures and time.
What is the success rate for Plantar Plate repair surgery?
Dr. Baravarian’s success rate is currently over 95%. The level of total correction can depend on the amount of damage, but basically, it is always repairable.
Can you recommend some good shoes for plantar plate injuries?
A shoe with a stiff sole is recommended for plantar plate injuries. If you are looking for athletic footwear, Hoka is a good brand.
