New and ready to learn with a plantar plate tear case!

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Hello All:

I want to begin by complementing everyone here on the fantastic quality of information available on this forum. I am not personally a podiatrist, but the members here are on the whole an absolute credit to the profession.

I am recently graduated with my doctorate in physical therapy, and practicing in the USA. Generally, I became a member here so that I can have full access to the interesting and informative images posted, however, I did have a case recently that I would appreciate some input on.

Female high school cross country runner with a history of forefoot pain x2 seasons (would appear and increase with mileage, then decrease/abate after the season was over). Finally this year after getting some new shoes the pain sharply increased, and she was unable to run through it. She went to see a podiatrist due to some swelling (mainly in the region of the metarsal heads, but also through the longitudinal medial arch) and pain with WB, worst from heel off to toe off. She had negative plain films of the foot, and the podiatrist made a clinical diagnosis of 2nd digit "predislocation syndrome." The podiatrist prescribed RICE for 4 weeks, including a walking boot. She was referred to physical therapy due to concomitant patellofemoral pain syndrome (PFPS).

Her PFPS seems to be part of the classic female kinetic chain problem: genu valgum with weak proximal hip musculature, leading to over pronation and flexible pes planus. On my personal clinical examination she has some mild bilateral plantar fasciitis, tight gastrocnemius, and residual swelling through the medial longitudinal arch/over the metatarsal heads of the affected foot. She is still having pain in the region of the 2nd MTP joint that starts plantar and moves dorsal as it worsens (about 6/10 "ache" at the end of the day). There is a dorsal drift on her 2nd digit and medial deviation, as well as weak/incomplete flexion, when she attempts to flex the digit. It has been 4 weeks since the initial injury, and 2 weeks since her podiatry visit.

My Question! I have not dealt with "predislocation syndrome" or a plantar plate tear previously. I read some of the excellent threads available on this site, as well as this article: http://www.podiatrytoday.com/article/6822 What I am looking for is an anatomical explanation for the dorsal drift of the digit and why her plantarflexion of that digit is weak or incomplete. In the state where I work physical therapists do have "direct access," meaning self pay clients can come in without a referral. In these cases it is very important for me to be able to screen for issues outside my scope of practice which may necessitate a return to a primary care provider. Finally, the podiatrist has ok'd her trial return to running at week 4 - and said that the same shoes would be appropriate. These are the shoes: http://www.footlocker.com/product/model:148023/sku:080138/?cm=GLOBAL SEARCH: KEYWORD SEARCH

While I like these shoes for this patient because they provide a very firm heel cup (preventing calcaneo-valgus, which she is prone to) and have the Duomax foam medially to help prevent overpronation, I'm not so sure about the "break point" for the Duomax foam. Since it ends just proximal to the MTP, resulting in a relatively flexible forefoot (possible MTP hyperextension?), is this a bad choice for someone with "predislocation syndrome" tendencies? I'm particularly worried about it since her clinical history correlates the increased pain with the introduction of these new shoes.


There is so much for me to learn here! I would appreciate anything from personal replies to links to appropriate articles. I've seen a few threads on here about incompetent physical/physiotherapists and I hope that being involved/becoming more informed will help keep me from becoming a part of the problem. Thanks in advance!

 

Podiatry arena is cool, hey!

For females in this age group, you need to think about freiburgs disease (avascular necrosis of the lesser metatarsal heads). I know the xrays were negative, but in early stages this can be the case.

No matter if it's plantar plate tear, 2nd met capsulitis or frieburgs, I would make custom foot orthoses to resist the excessive pronation, and specifically modify them to reduce the force on the painful metatarsal heads. I bet that would do the trick pretty quick. Also, they would help the plantar fasciitis and patellofemmoral syndrome too.

Also, get some gastroc + soleus stretches happening, as tightness will be increasing the load on the metatarsal heads.

As for the shoes, i think the 1160 Asics are a bit crap. I prefer the 21XX series or the kayanos if shes keen on Asics. But that's just my opinion, having worn them all.

 

Thanks very much for your reply, Phil.

We have been doing gastroc/soleus stretches as well as subtalar medial glides to help promote better neutral position. As you know, good neutral foot position is key to helping reduce PFPS symptoms.

I don't know too much about the podiatrist's reasoning to rule out conditions such as Frieberg's Infarction, but from a clinical perspective, I'm just curious as to how you typically find it presents clinically. Can you effectively differentiate it from MTP synovitis, "predislocation syndrome," or a plantar plate tear with clinical assessment in the early stages?

What is your complaint about the Asics 1160's specifically? I've personally run in the earlier makes (Asics 1140's) and preferred them to the 2000 series because the 2000 series are too squishy in the padding for my taste. The don't feel as stable, even with the Duomax foam in the same location.

 

DPT welcome to PA and can we know your name please? You may want to review this thread first.

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=53237

I don't think many people here would agree with your statement above. You have to first identify the structure causing symptoms and the forces causing those symptoms. Your goal is then to reduce those forces, often it this achieved with foot orthoses. This is the Tissue Stress Theory.

PF can have a number of biomechanical causes, some tend to appear as findings more than others but in the end STJ neutral is a finding and one that many cannot agree on and not a treatment.

 

Good test for plantar plate integrity

Stand on the yellow pages with the toes hanging over the edge. If the 2nd toe points up in the air or is dorsiflexed significantly more than the others with little resistance to dorsiflexion, there is most probably a plantar plate tear.

Agree with checking out Freiburgs

Good thing is to tape the toe down as described in the plantar plate anatomy thread. if the symptoms reduce just from doing that, then , again there is probably plantar plate involvement.

Then consider offloading as per described in the other threads. Custom made is best option but by no means the only one. Have had good success with modified prefabs

Robin

 

Thanks for the reply, David, and for the link to more plantar plate threads. I've perused some of these already, but its nice to have them listed all in one place.

Looks like I dug up an old issue with my "neutral foot" statement! I'm very aware that the causes of PFPS are varied and that treating each case alike (treating everyone by correcting their foot position, for example) will lead to failure.

That being said, the thread you linked me to has a wealth of information on subtalar neutral which is (mostly) new to me! We get a short section on that topic and it's much more cursory than the discussion provided there! I'm looking forward to some good reading.

 

DPT2012:

A real name would be helpful here and get you more responses to your questions from many of the contributors on these threads.

The reason that a plantar plate tear causes a dorsiflexed digit is that when the plantar plate is torn, the slip of the plantar fascia that attaches to the base of the proximal phalanx of the affected digit is, basically, also torn. Biomechanically speaking, the plantar fascia and plantar plate provide a passive source of metatarsophalangeal joint (MPJ) plantarflexion moment that produces increased digital purchase force during normal weightbearing activities. Tearing of the plantar plate will reduce, therefore, the main source of passive MPJ plantarflexion moment, tend to create a digit with decreased purchase force and, over time will create a dorsiflexion deformity of the lesser MPJ and a hammertoe or clawtoe deformity.

If the medial aspect of the plantar plate is torn, the toe will deviate laterally and dorsally. If the lateral aspect of the plantar plate is torn, the toe will deviate medially and dorsally.

The best clinical tests for plantar plate tears are as follows:

1. Tenderness at the plantar base of the proximal phalanx of the affected digit associated with plantar edema (most plantar plate tears occur distal to the plantar plate at its attachment to the proximal phalanx base).

2. Pain and increased MPJ plantarflexion stiffness with plantarflexion of the MPJ by the examiner.

3. A positive vertical drawer test (i.e. Lachman's test) of the affected MPJ.

4. A lack of normal digital purchase force or a dorsiflexion deformity of the MPJ during relaxed bipedal stance.

Finally, do not allow the female runner to continue running without some form of foot orthoses with an accommodation for the affected MPJ and having the toe taped to restrict dorsiflexion or the pain will probably immediately return and the deformity may increase. Daily plantar icing therapy, 20 minutes, twice daily, also works very well for these patients. As others have stated, Freiberg's infraction, metatarsal stress reaction/stress fracture should also be ruled out in these young athletes.

Hope this helps.:drinks