Plantar Plate Tear / Repair
The plantar plate of the lesser toes is a thick ligamentous structure that lies underneath the metatarsal heads in the ball of the foot.
- It provides stability and support to the knuckle joints (metatarsophalangeal joint (MTP joints)), which are the joints connecting the metatarsal bones to the phalanges (toes).
- You walk on your plantar plate rather than the metatarsal head.
- Injury or damage to the plantar plate can lead to a condition known as "plantar plate tear" or "plantar plate attenuation."
- If stretched or torn the pressure is felt by the skin under the plantar plate and a callus can build up
Here's some general patient information about plantar plate injuries from my point of view and is not exhaustive. It is also like the art of surgery an opinion and others are available! :
- Overuse or repetitive strain on the foot due to activities that put excessive pressure on the ball of the foot. An example being tight calf muscles in athletes
- Trauma or sudden injury, such as stubbing the toe or dropping a heavy object on the foot.
- Chronic conditions that affect the foot, like inflammatory arthritis, Bunions or Great Toe arthritis.
- Pain and tenderness in the ball of the foot, particularly under the affected toe(s).
- Swelling and inflammation around the MTP joint.
- Difficulty bearing weight on the affected foot.
- A feeling of instability or the sensation that the toe is "popping" out of place.
- Splaying of the toes creating a ‘V’-shaped deformity
- Development of a Claw Toe position
A healthcare professional, usually a podiatrist or orthopedic specialist, will conduct a physical examination of the foot. They may also order imaging tests such as X-rays, ultrasound, or MRI to assess the extent of the injury and rule out other potential causes of foot pain.
Typical tests of the affected toe that would be in your notes or letter would include a positive Lachman’s test and tenderness at the insertion on base of proximal phalanx.
Commonly it needs to be differentiated from a Morton’s Neuroma that can be present or associated. Other conditions such as stress fractures, Freiberg’s disease or Inflammatory/Osteo Arthritis will be considered.
The treatment approach for plantar plate injuries depends on the severity and acuity of the condition. It may include:
- Rest: Avoiding activities that exacerbate the pain and allowing time for the injury to heal.
- Ice: Applying ice to the affected area can help reduce inflammation and alleviate pain.
- Medications: Over-the-counter pain relievers like ibuprofen or parcetamol can help manage pain and reduce inflammation.
- Immobilization: The use of a splint, tape, or orthotic devices to stabilize the toe and reduce strain on the plantar plate.
- Toe taping both helps you but also, through providing improvement whilst worn, establishes with more certainty the diagnosis
- Physical therapy: Specific exercises to strengthen the foot muscles and improve flexibility may be recommended.
- Corticosteroid injections: In some cases, steroid injections may be used to reduce inflammation and pain.
- Shoe modifications: Wearing shoes with a wider toe box and good arch support can help reduce pressure on the ball of the foot.
- Surgery: For severe cases or cases that do not respond to conservative treatments, surgical repair of the plantar plate may be necessary. The animation below explains this.
Plantar Plate Tear / Repair
Plantar plate repair surgery:
If you decide to request to undergo the surgery after counselling you should be aware of the Preparation, Surgery, Recovery and Risks.
- The operation requires your bones to heal like a fracture. Optimising your nutrition particularly Vit D and Calcium is very important. Supplements from healthfood shops can support this.
- Do not smoke in the lead up or during the recovery of this surgery. It has a big impact on bone healing I would counsel against this operation if smoking or (in my opinion) using nicotine containing Vapes
- Clear stress if you can. Plan for 2 weeks off work in the initial recovery to include home working if stressful. I do feel the stress hormones are not good for recovery can affect wound healing maybe bone healing too.
- AVOID ANY cuts or bites to your leg. Your foot / lower leg skin condition must be ideal for this surgery to proceed.
- Reduce risk of Thrombosis/DVT/Blood clots in leg.
- This is a serious condition that , whilst rare, can be dangerous.
- To help you should prepare to stay hydrated and get used to drinking good volumes of water.
- Discuss with your surgeon about stopping any HRT or contraceptive pill around the time of surgery – Do alert them if unsure.
- Be ready to where a TED stocking on the other leg after the surgery whilst immobile
- If you have risk factors for thrombosis or you / a family member has one before you may consider taking an injection to thin your blood whilst you are immobile. TELL YOUR SURGEON before the day of operation if this sounds like you.
- A Thrombosis in the leg is felt as a swelling or cramping pain in the calf of either leg that can feel like a sports cramp that doesn’t go away. Quite simply if you are ever concerned about symptoms like this after this surgery contact the hospital or go to your local ED for urgent assessment.
- This is usually a daycase procedure
- You must prepare for a general anaesthetic. Whilst Local anaesthesia is used with sedation in appropriate cases follow rules for a full general anaesthetic.
- Afterwards you will be fitted with Surgical sandal to protect the operation
0-2 weeks – Surgical Phase – get the wounds healed safely
- Elevate the foot rested at home. Ideally 45-50mins of each hour – “Toes above your Nose” reclined on the bed or couch with your foot up on pillows
- Move your knee and ankle, hip etc regularly to help your circulation
- Drink plenty of water
- Wear your TED stocking (Flight sock)
- Wear your surgical sandal day and night to protect the toe.
- You can Fully Weightbear on your surgical sandal when you need to. (Unless specifically told not to)
- Leave any wires / pins (if any) you can see alone.
2-6 weeks – Recovery Phase – function whilst protecting the operation
- Continue to wear your sandal day and night
- Begin to walk increasingly further distances gradually stopping if you ever experience pain or swelling. Expect to effectively ‘potter around at home’ or travel short distances in the car as a passenger etc.
- After the 3rd week you can consider driving short distances only if it is your LEFT foot operated on AND you have an automatic car. You must feel safe and confident your toe can rest in the seated position for the duration of any planned journey.
- Keep toe taped except for any prescribed exercises. This can be exchanged for hygene as needed
- Watch for complications – See ‘ I’ve Had Foot Surgery’ Advice page/sheet
6 wks–6 months – Rehabilitation - Regain function and feel the benefit
- Follow guidance with regards any exercises and toe taping
- Wean into soft insert shoes (Memory Foam is very good) then as comfort allows try more formal shoes before finally walking barefoot last as this will stress the surgery the most.
- Discuss with surgeon about any previous insoles used etc.
- Expect mild swelling and even other toe soreness as the foot accepts the new positions, scarring etc.
- Only build up sports as guided by your physio or surgeon.
- It can take 6 months to feel the full benefit and the operation to fully settle down
Risks of surgery.
Whilst minor. There are always risks to any operation.
You will have to undergo either general anaesthetic or local anaesthetic and sedation. This does involve taking medications by a drip or Injection. Occasionally tablets. You will be given local anaesthetic. There's always a small risk you can have a reaction to these. In the form of allergy. A general anaesthetic or sedation places your heart, Breathing and nerve system under stresses that will be discussed with you by your anaesthetist.
Bleeding. Bleeding is unusual to be significant. There will always be a little bit of dry blood on your dressings when it's checked at two weeks. This is not a significant concern. If you take any medication that thins your blood this will be discussed with by your surgeon. It can increase the small risk.
Infection. An infection is a concern In the foot. It is low down and near the ground. It does carry more bacteria on the skin. If these get into the wound it can cause local infection. A small skin wound infection is not actually that uncommon (At around one in 20 patients). This is usually managed very simply by early recognition in the clinic or by a nurse or even yourself. Treatment with antibiotics will resolve the majority of these.
If ever infection gets into the bone, this can be far more serious, involved prolonged treatment and even runs a small risk of loss of the toe itself. This is indeed very unusual. During the surgery, your skin will be prepared with antiseptic's and be performed in a ultra clean environment. Your surgeon will do everything they can to avoid infection at that stage.
To help yourself, you must avoid swelling through keeping the foot elevated, quotes, toes above nose quotes. You should avoid smoking. And naturally keep the dressings clean, not inspecting yourself unless instructed otherwise.
Infection can present as new onset worsening pain that is unexpected during the initial recovery. If that should happen, you should inform your surgeon or the hospital so the wound can be checked.
Nerve damage. In the initial recovery following surgery the area around the incision site will be a bit numb and tingly due to the local nerves from the cut. It is normal and should resolve in time.
There are two main nerves that supply each toe that is being repaired and if either of these are damaged, it can lead to some tingling in the toe or even permanent loss of feeling in the toe. It should not have any effect on the strength of the toe. If you're feeling doesn't recover after the operation in the first two weeks, do discuss this with your surgeon.
Fracture / broken bone. During the surgery it is necessary to cut very small bones in your foot with a saw. ( metatarsal ) and also pass fine drill holes. It therefore is of course at risk of the bone breaking. If it happens during the surgery consideration to how to repair it will of course be undertaken.
It could also happen in the recovery. when walking in the shoe and would present as increased pain or swelling, possibly following an injury or stabbing of the to. Despite the sandal, you should get this checked. If it happens. It can compromise the overall result of the surgery. Leaving a stiffer., more swollen or more painful toe and hence disappointing result.
Non union. The surgery involves the cutting of the metatarsal with a saw. It is then held back in place with a small screw, but it is necessary that your bone then heals back together again, much like a broken bone or fracture would. Sometimes this process is not complete and it fails to unite. Should this happen further surgery or procedures can be required or considered. It can compromise the result with stiffness, pain or poor function. It is, however, very unusual.
Avascular necrosis. (AVN). This is the technical name. For bone crumbling and dying as a result of the blood supply not returning after the saw cut has been made. This can lead to arthritis in the toe, pain and a difficult sore problem long term. All care and attention is made to protect the blood supply in the surgery, but despite this, it can still happen. If you get worsening pain at the base of the toe. Usually from three to six months after the surgery or longer this should be alerted to your consultant.
Swollen toe. You're toe will be swollen after the surgery for up to six months, quite predictably and quite normally. However, in some instances it can be prolonged. Even permanent. Whilst this is not dangerous, it is clearly frustrating.
Stiffness or Malalignment. Your toe will be held in a taped position to protect the repair of the plantar plate. At about six weeks you will be encouraged to begin to manipulate the toe gently and try and regain movement of the joint whilst not damaging the plantar plate repair. Occasionally this remains stiff and the toe can rest in a less than perfect position. This might be either below or above the level of the other toes and cause a frustrating awkwardness with getting into a shoe or catching it when walking barefoot. Again, it is not dangerous but can be frustrating. Occasionally a brief procedure to manipulate the toe can be considered. Re-operation is rare but scar tissue is sometimes is excised.
Re-rupture/Re-tear. This is very unusual but we would only expect that scar tissue that forms following the surgery will be slightly weaker than the original planter plate you were born with. Therefore, if you have a further injury It could happen again. For this reason your surgeon will look to any deformities in the rest of the foot, including the great toe to consider treating any background cause for the plantar plate tear in the first place.
Loss of toe. This very rare complication must be accepted if you request toe surgery. It can come through infection or failure of blood supply to return. It can happen from surgical accident as power tools are used etc.
Thrombosis. As mentioned above, you will have a small risk of thrombosis following this procedure. You must discuss with your surgeon any risk factors. It is likely you'll be advised to temporarily stop any HRT or COCP. This is, of course, balanced against the complications associated with stopping these Including withdrawl effects etc.
COVID. The current advice I follow is, as of writing this document (July 2023) that elective surgery like this should not be considered within seven weeks of a confirmed bout of COVID.
Metal work issues. The procedure will involve a small screw being inserted into the metatarsal. This supports the bone cut that was made. This screw is designed to be. Very small and you should not feel it. There is a small risk, however, that it could be a bit prominent or back out or even break. If that's the case A further operation can be required. If you have any intentional pins in your toe after the procedure that you can see sticking out. You must watch out for any signs of pus, redness or backing out of the wire and alert your surgeon urgently.
Shorter toe. It is quite common after this surgery. (As bone cuts are made). For your toe to appear a little shorter than the others. This can be unavoidable and almost is expected. It will of course, be minimised to the best of the surgeon 's capabilities.
Transfer metatarsalgia. This refers. To symptoms after this surgery. Beginning on toes either side in the same foot. The four foot. Is in perfect balance. In the normal foot. And once it is changed through damage or even through surgery. It can affect the balance of all the five toes and the way pressure is put upon them. Following the surgery, it is possible to have pressure felt on other toes and pain develop there.
It's essential to consult a healthcare professional for an accurate diagnosis and personalized treatment plan. Self-diagnosis and self-treatment may worsen the condition or lead to complications.
If you would like to arrange a consultation to discuss your foot or ankle problems with Mr Williams, then please contact us.