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Interesting Case Study: Multiple plantar plate tears!!

Discussion in 'General Issues and Discussion Forum' started by hwelli10, Dec 10, 2011.

  1. hwelli10

    hwelli10 Member

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    Hi everyone,

    Had a really interesting case enter the clinic recently and thought i'd share it with you. I would greatly appreciate any advice, had difficulty deciding where to start!

    38 y/o female, unbearable forefoot pain for several months however has had general foot pain for years. Works in retail, 10-12 hour shifts on concrete floor. Footwear not great, no cushioning, slight 1-2inch heel. Rated pain as 9/10 on VAS, no refielf of symptoms unless resting completely.No hx of inflamatory arthropathies

    Clinical assessment: forefoot swollen, plantar and dorsal, very painful on plapation of all plantar mets, inter-met space, dorsal and plantar pain. Ordered x-rays to investigate inflam arthropathies, OA, Joint boney injury. Results all normal appearance. Then ordered US, now it gets interesting!!

    Right 1st - full thickness plantar plate tear, appears long standing, joint effusion but no bony irregularity
    R/2nd - 5mm plantar plate tear (PPT)
    R/3rd - 2mm PPT
    R/4th - 6mm PPT
    R/5th - 4mm PPT, joint effusion noted, no bony irregularity

    R/3rd inter-met space - Morton's Neuroma

    Left 1st - joint effusion, no bony irregularity
    L/2nd - 4mm PPT
    L/3rd - 1mm PPT
    L/4th - complete PPT
    L/5th - 2mm PPT

    L/2nd intermet space - prominant bursitis, extending to platar fat pad
    L/3rd intermet - Morton's neuroma!!!!

    It is unbelievable this woman can even stand! Have been padding and strapping her feet to offlaod and dorsiflex all mets, advised on footwear.
    Can't stop going to work as feels they need her now as it's so busy.
    I am referring on to surgeon, organising G.P to provide work leave. No point in custom orthos at the moment until Sx gives his opinion.
    Will continue padding/strapping/offloading short-term.

    Any other suggestions??
  2. Admin2

    Admin2 Administrator Staff Member

  3. I wouldn't get too excited. Plantar plate tears are very common...in one study 96% of metatarsophalangeal joints had at least a small plantar plate tear.

    Gregg JM, Silberstein M, Schneider T, Kerr JB, Marks P: Sonography of plantar plates in cadavers: Correlation with MRI and histology. Am. J. Roentgenology, 186:948-955, 2006.
  4. G Flanagan

    G Flanagan Active Member

    Seems to me the Radiologist / Sonographer may have been getting a bit too enthusiastic
  5. emmakh

    emmakh Welcome New Poster

    Hi hwelli10,

    I have also just had an US report come back with similar findings:

    Plantar plate tears:
    R/1st - 5mm
    R/2nd - no tear
    R/3rd - 4mm
    R/4th - 3mm
    R/5th - no tear

    L/1st - 5mm
    L/2nd - no tear
    L/3rd - 3mm
    L/4th - 3mm
    L/5th - 2mm

    My patient is a 68 year old man who presented c/o pain in both feet, L>R, getting progressively worse over the last 12 months. The patient was previously walking 4-5km a day but is now unable to do so because of the pain, and has since put on 15kg. The patient has a cavoid type foot with very heavy foot contact at heel strike and little shock absorption.

    I was surprised to read that multiple plantar plate tears are so common, as in most cases I have only seen a plantar plate tear of the 2nd MTPJ. If this is the case is it still best to treat it conservatively (ie. taping, padding, rest) or is something more aggressive needed?

    I would appreciate any further feedback/suggestions regarding this?

  6. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    The golden rule of podiatry and medicine is, in the absence of medical emergency (which is extremely rare in our field):

    Try and fail at conservative care before considering more aggressive, invasive and riskier interventions.

    Any foot surgeon worth their malpractice insurance will send them back to you for orthotics/footwear/physical therapy before considering surgical options.

    I would design a custom orthosis with metatarsal bar to float the heads, appropriate shoe gear, and give things 3 months to settle. There may inevitably be a surgical solution required, but only after conservative care has been genuinely and competently administered.

  7. Ian Linane

    Ian Linane Well-Known Member

    If it is of any use at all I have often used the taping procedure for pre-dislocation syndrome to aid in the healing process of plantar plate ligament injuries. It can bring some reasonable relief to the patient in weight bearing if any instability in the joint can be controlled.
  8. hwelli10

    hwelli10 Member

    Hi Emma, I am still in the process of treating my similar patient. I began with padding/strapping in attempt to dorsiflex the joints, obviously these things crop up when you have long periods off (mine was over christmas) and orthotic labs close!! eventually got her into custom ortho, met bars and rearfoot control, arch capture (also cavus foot type). she is still in considerable pain but we are waiting to see how it pans out. footwear has been an issue, more so because of non-compliance however (there is only so much you can do!!)

    Plantar plate is very common (as studies show), just most people are unaware of it! i suppose the trials were done on cadavers (with no voice) and we'll never know if they experienced any pain with their plantar plate tears! my poor lady was just in unbearable pain and couldn't fit footwear her feet were so swollen and she like your patient was very active. On her feet everyday with work for 10-12 hour shifts.

    Surgery is always last resort but she is aware that may be a possibility if symptoms do not lessen in the next few months! Thanks LuckyLisfranc on waiting times to see effects, wasn't too sure how long to let symptoms persist.

    Funny really because after this patient (my first symptomatic plantar plate tear) i had my run of plantar plate tears! i find it very interesting how certain ailments crop up together and at certain times of the year, may make an interesting research!

    Thanks guys for advice and similar stories, glad i took right steps, will have to continue monitoring!

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