There are many causes of ball of foot pain. Often, ball of foot pain is associated with poor footwear, lots of walking, and a Morton’s Neuroma. Not often do we hear the word plantar plate tear, but are clinically more common than a Morton’s Neuroma.
The plantar plate is a strong supportive ligament which is unlike any other ligament in the body, it’s a thick structure that provides significant stability to the toe. It begins at the metatarsal head and extends down to the base of the proximal phalanx under the foot. The plantar plate is responsible for holding the toe down straight. It also connects to the plantar fascia and serves an important role in foot function. It has very complex anatomy.
Often, we see misdiagnosed forefoot pain as metatarsalgia, but often that is not the case, nor is it a diagnosis. It goes back to the old saying, ‘if you’re not looking for it, you will never find it!’
What are the causes of Plantar Plate Injury?
Plantar plate tear or injury are one of the most common reported problems with 2nd MTPJ pain, and the diagnosis is usually via clinical tests and imaging. Often, there is an underlying biomechanics issue which has resulted in the plantar plate tear. This can be anything from bunions, reduced 1st MTPJ ROM, irregular metatarsal length, increased plantar pressure and sometimes a single incidence of dorsiflexion of the toe (let’s call it hyperextension of the toes).
How does a Plantar Plate Tear or Injury present?
In clinic, plantar plate injuries usually presents with pain either on the bottom of the foot or sometimes the top of the MTPJ as an ache. There may be swelling but often the injury may already be chronic and no swelling is present. Pain in the plantar plate is often reported on weight bearing activities such as walking, running, dancing and particularly barefoot walking. There is also reduced plantar flexion strength. Unmanaged plantar plate tears often result in a ‘floating toe’ or hammer toe.
Plantar Plate Treatment.
Plantar plate tears and injuries need to be appropriate diagnosed, classified and rehabilitated in order for the best prognosis. These injuries if left untreated can result in significant pain and deformity to the foot. Treatment can include activity and footwear modification, strengthening exercises, strapping, and orthoses. A combination of offloading and intrinsic foot muscle exercises and rehabilitation is our first point of call and is often successful. It is very important to remember that addressing biomechanics issues is a must. If all else fails, surgery is an option, but often the last option. The ligament has a complex function and the goal is to reduce as much stress from the tissue as possible.
This is not an injury where the joint is cracked, manipulated or mobilised. This will result in the ligament tear worsening and further pain.
We recently had a lovely gentleman present with increased forefoot pain post holiday. He reported getting dumped in the surf before the pain started and awaited a consultation with his GP when he arrived back home. The gentleman had increased ball of foot pain and swelling resulting in cessation of walking and activity.
His GP sent him for an MRI with an apparent ‘infection’ in the foot which the gentleman took antibiotics for. This did not help the pain. 2 weeks later the gentleman presented to us and assessed. A diagnostic musculoskeletal ultrasound was performed with manual testing and a diagnosis of a plantar plate tear was made. Here is the ultrasound performed.
After offloading, strapping and exercises, pain reduction was achieved rapidly. A plan was put in place to help manage the tear, as it is full thickness through the tendon, permanent orthoses would be required to provide permanent relief. Otherwise, surgery is indicated and the gentleman was not wanting that as a first line of intervention.
We treat plantar plate tears every day successfully and can help you too. Struggling with ball of foot pain? Make sure you get the diagnosis right first before commencing any treatment. Let Eltham Foot Clinic help you today.