Plantar Plate Repair Surgery

What Is A Plantar Plate Injury Of The Toe?

A plantar plate injury refers to damage to the strong supporting ligament of a toe, located on ball of foot.  The plantar plate is not an ordinary ligament as it’s a thick structure that provides significant stability to the toe.  Most commonly the 2nd toe is involved, but any toe can be damaged.  Plantar plate injuries can be acute or chronic.

Symptoms & Causes Of A Plantar Plate Injury

Patients can sustain an acute plantar plate injury where the ligament in torn or can develop a slow tear.

Acute Injury: Symptoms of acute injury to the toe can be pain and swelling depending on just how the injury occurred.   Injuries tend to occur from sudden and excessive upwards motion of the toe.  Sometime this can be an explosive injury or a small injury from excessive walking.   A tearing sensation can be felt in some people.  The toe can dislocate and ‘pop’ back into place.  Bruising is common with severe injuries.  A plantar plate tear can render the toe unstable, and if not treated develop into hammer toe problem.

Chronic Injury:  A chronic plantar plate injury is very different than an acute injury.  Here the plantar plate (ligament) will have micro-tears and stretch out over time.  A chronic injury can occur from a trauma where the initial plantar plate tear was undiagnosed – this is best considered a non-healing injury.  Alternatively a chronic injury of the plantar plate may occur from biomechanical imbalance to the foot where repetitive stress causes repeat tearing.  Chronic (or nonhealing) plantar plate injury can develop into a hammer toe.  Pain is often present on the ball of the foot, and the toe may become severe deformed.

Diagnosis Of Plantar Plate Tear

Diagnosing plantar plate injuries can be challenging for a variety of reasons, which will be outlined.  Acute injuries where there is obvious instability of the toe with pain located on the ball of the foot (directly) over the plantar plate are straightforward.  However, most injuries are subtle – whether acute or chronic.

The exam will often demonstrate pain in the area.  In a peer-reviewed article published by Dr. Blitz in the Journal of Foot & Ankle Surgery, he indicates that the pain is often located closer to the toe on the bottom of the foot, rather than directly on the ball of the foot.  This is because the plantar plate tear or injury occurs very close to where the ligament attaches to the bone on the toe.

There is a maneuver to test the integrity of the ligament, but is often unreliable.  This test is called a Lachman’s test, which is orthopedically known as a drawer test.  Here the toe is lifted superiorly to see if the joint can be manually dislocated.  Obvious cases are obvious, of course.  Mild and moderate displacement is a gray zone.

Xrays have limited utility as ligaments can’t be visualized.  However, surgeons can ascertain information about the joint alignment which can suggest a plantar plate injury.  Toe dislocations are usually obvious (and uncommon) but are indicative of a plantar plate injury.

Magnetic Resonance Imaging (MRI) is very helpful with plantar plate injuries as its non-invasive and allows for direct visualization of plantar plate.  However, MRI is not perfect and small or mild tears can be missed or poorly identified – even by the most experienced.

Arthrogram is the best way to determine the integrity of the ligament structures (plantar plate) surrounding the joint.  The test is invasive, however.  A needle is inserted into the joint and radiographic dye is injected to see if any fluid leaks out.  An arthrogram will not indicate severity, only integrity.

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Non-operative Treatments for Plantar Plate Injury

Non-surgical methods for plantar plate injuries are categorized into acute and chronic problems.  So long as significant toe deformity hasn’t occurred – which often happens with chronic problems.

Acute Injury
Acute plantar plate injuries should be evaluated by a foot surgeon to determine if surgery is indicated.  If not, the toe can be taped and splinted to allow the plantar plate to heal.  There is a specific type of taping for this injury and should be performed by an expert.  In some cases casting and crutches are necessary for 6 to 8 weeks.

Chronic Injury
Chronic injury of the plantar plate are treated similar to hammer toes, and treatments are geared towards decreasing pain.  Treatment will not restore any malalignment of the digit (if present).

Simple treatments patients can do for CHRONIC plantar plate injuries are:
•    Wear supportive shoes
•    Use an arch support
•    Wear shoes with a wide toe box
•    Modify activities
•    Spot stretch shoes
•    Periodic callus care

Non-surgical treatments Dr. Blitz can add:
•    Anti-inflammatory Medicines: Prescription strength medicines to decrease pain and inflammation.
•    Physical Therapy: To strengthen poorly functioning muscles and stretch tight muscles that may be exacerbating the toes.  Special ultrasound techniques may reduce inflammation.
•    Custom Foot Orthotics:  Dr. Blitz creates an orthotic with an exact mold of your foot to better align and support the foot to ease current discomfort and prevent future progression.
•    Toe Splints or Pads:  Specific pads may prevent pressure and physical irritation in shoes.  Toe splints and toe spacers physically realign the toes and can lessen pain and halt or stall hammer toe progression.
•    Plantar Plate Toe Taping: Taping the involved to in a basket weave fashion to
•    Injections:  Cortisone injections are strong anti-inflammatory agents to decrease pain, and swelling directly at the toe region.  Injections only treat the symptoms, and in some cases used in caution (and sparingly) they can weaken supporting ligaments of the toe(s).

Plantar Plate Tear Surgery

Plantar plate tears can be repaired with surgery.  Both acute and chronic injuries can be fixed.  The method of repair mainly depends on extent of injury to plantar plate ligament, cause of tear, time from injury, the presence of a toe contracture (hammer toe), and overall biomechanical foot structure.

Acute Plantar Plate Tear Surgery

Dr. Blitz’ pioneered the technique for plantar plate repair, which was published in the Journal of Foot & Ankle Surgery.   The basis for plantar plate tear surgery involves directly repairing the tear by sewing the ligament (plantar plate) back together in the proper position.  This is medically called ‘Primary Repair’ of the plantar plate.  Simple tears are straightforward.  A complex tear where the plantar plate is shredded of requires special plastic surgery techniques to get the ligament ends together.  Severe tears where the plantar plate is pulled off the bone involves using a special bone anchor secure the ligament to the bone.

Chronic Plantar Plate Tear Surgery

Chronic plantar plate injury surgery is not as straightforward as acute injury.  While Dr. Blitz’ has pioneered repair techniques for repair of the plantar plate, he believes that chronic injuries need to be thoroughly evaluated before simply repairing the tear.  The problem with chronic injuries is that secondary compensations of the toe may have set in, making repair of the plantar plate secondary to a larger problem.  Dr. Blitz considers plantar plate repair with all chronic injuries but may need ancillary procedures to balance the toe, especially when the toe becomes chronically dislocated or buckled (hammer toe).  For more on hammer toe surgery – see Dr. Blitz section on hammer toes.

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Plantar Plate Surgery Recovery

Typically recovery after direct repair of the plantar plate is about 4-8 weeks in healthy people.  The plantar plate is strong ligament that takes time to heal, and there is no way dramatically expedite the healing process.   Patients need to be off the foot while the repair heals, and crutches are often needed.  The foot can be placed in a surgical shoe, removable boot, or cast depending on the extent of the repair. Should the toe require additional procedures to correct a hammer toe (in present) then recovery could change.   In general, a return to regular shoe gear may occur from 4-8 weeks after the plantar plate surgery.

What Are The Risks Of Plantar Plate Surgery

There are general risks associated with toe surgery (or any surgery) and the use of anesthesia.  Complications may occur and are not necessarily your fault, or the fault of your surgeon.  Nonetheless, you should understand the risks.

Toe surgery complications include, but are not limited to: infection, pain (temporary or permanent), swelling, hematoma, bleeding, blood clot, poor wound healing, incision breakdown, poor bone healing (delayed union, nonunion), malunion, nerve injury, disability, recurrence, flail toe, new toe deformity, metatarsalgia, unsightly scar, stiffness, shortness of toe, weakness in toe, loss of toe to purchase ground, hardware problems, need for revisional surgery, and/or catastrophic loss.

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