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Plantar Plate Anatomy re Plantar plate tear

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Jun 17, 2010.


  1. Members do not see these Ads. Sign Up.
    I seem to be dealing with plantar plate problems more and more .

    Or I´m looking for it more and more, anyway information is Quite limited when trying to give patients information. I found this which I though was great and with pictures that can help explain whats going on to your patients.

    Hope you also find it useful
     
  2. bob

    bob Active Member

    Thanks for that (even though I've read it before).
    What do you do when you suspect plantar plate tear? - investigations and treatment?
    Depending on your local sonographer, I usually get a decent ultrasound scan to accompany the clinical signs and symptoms. Treatment wise, I discuss options with the patient - orthosis with relief area +/- toe alignment splint. If conservative care fails, or if it's chronic, I'll offer plantar plate tear repair +/- bone surgery to address any contributing bony pathology.
    I have previously performed plantar plate tear repairs based on MR scan reports and clinical signs and once I've actually got in there I've found no obvious pathology! So the patient departs with a plantar scar for no reason. I did not think this was reasonable, so now I prefer ultrasound scans.
    Do you do many plantar plate tear repairs?
     
  3. Hi Bob no Knife in my kit bag so conservative as much as possible.

    Investigations - Symptoms from patients - palpation of area, look for mulders click in an attempt to rule out Mortons, Usually add tension to plantarfascia and palpate to compair and contrast with palpation with no extra tension, Full biomex and gait exam. I would love to ultrasound but no machine (yet its another :santa: present after CAD/CAM ) I can´t refer direct to MRI or Ultrasound here ( only orthopeadic surgeons , a whole other frustrating story )

    Treatment in 2 stages at moment, ice 1-2 twice a day 25 mins, stiff soled shoes, generally a heel lift to just behind the met heads and modified low dye taping for 4 days re assess, if positive response then orthotic with icing, heel lift, add stretching for gastroc-soleus, stiff soled shoes.

    Device is designed to reduce tension in plantar intrinsics and plantar fascia. Having very positive results at the minute.

    If response negative then try and get them into system for a MRI, which can take take some time.

    Surg is the next stage.

    As an aside question I had a patient who had a plantar scar for an Plantar plate investigation op, the patient is in 10 times more pain now, very local. Ive asked she get a MRI what would be the 1st things you would consider, as much as you can without seing the patient.
     
  4. bob

    bob Active Member

    Do they have any obvious plantar lesions in the scar? How long is it since their surgery? Maybe USS or MRI to check for any entrapment neuropathy as first treatment (you've already requested MRI). If there is any localised scarring or nerve lesions - might be worth trying corticosteroid injections (if you can do these under USS guidance, that'd be great). Obviously if these fail, revision surgery is an option. How much input do you have into the surgery? Do you have joint clinics with the orthopod or go into theatre with them at all? They really would benefit from your experience (and referrals), so they'd be crazy not to.

    Are there any podiatric surgeons in Sweden? Do you do nail surgery or have access to local anaesthetics? Do you have a national health service type system or is it fee paying/ private? What's your scope of practice? Apologies for my ignorance.
     
  5. Admin2

    Admin2 Administrator Staff Member

  6. Thanks for the info re the scar, after I get the results I might get in contact with some questions if thats alright ie start a thread.

    As for the questions above, I´ll give a brief run down. Podiatry is only 4 years old in Sweden. The 1st students to finish now have 1 year experience and the 2nd class should be finished as well ( in the last week)

    My degree is from New Zealand finished in 95 Aust reg Pod started up here in August of 2006 ( the 1st Pod to work as a Pod in practice as far as we can tell) The Swedish word for Podiatry is about 4.5 years old as well so a very new profession.

    The health system over here is government payed in general ie a socialist system. I as a podiatrist are unable to work as a Podiatrist within that system. I can work as another profession ie a foot therapist ( FHP I guess is the same in the UK) or I guess I could work as a orthopeadic tech, but notsure on that one. There are some of the Pods from the 1st year who are working within Diabetic team ( a great part of the system), but are far as I know their degree does not mean higher pay rates or increased scope of practice from a foot therapist ie if an orthotic is required to off load a diabetic ulcer they must refer to patient to the orthopeadic engineer department ( Björn is that still correct?).

    I think there is 6-7 people working this way and from all reports seem to be enjoying the work.

    In private practice at the moment there is me full time, one of the 1st grad group teachers 4 days a week and works private 1 day and there is another Pod not in Stockholm talking about starting a private practice.

    We mainly deal in MSK problems and I do some General TX, we do this with, no funding from the Governement ie the patinet pays. There is no real insurance pay as the system has not decided where Podiatry fits and what the Official Swedish Scope of practice will be..... This will take some time.

    So the patient pays which alot find a issue due to the very high taxs rates in Sweden.

    Anyway I cannot use local anaesthetics, I am not able to refer directly for X-rays- MRI only surgeons can ( I can but the patient would have to pay full fee, no one would or should)

    But appart from that which is huge section, Work as a standard Pod mainly in MSK related areas.

    As for working and being accepted by DrS, Physios, Surgeons etc some others not it all takes time, but I personally have found the ortho surgeons to be the worst group at wanting any of my options or advice, quite the opposite in fact, my option is not wanted. Maybe others have a better relationship. As for Podiatric surgeons none, yet.

    The school is closing here next year, but we hope and people are working towards openning the course again. I Hope it´s successful, In My option Sweden needs Podiatry.

    I could go on and on , maybe a thread on the different scope of practice around the world maybe a good idea.
     
  7. David Smith

    David Smith Well-Known Member

    Hi Mike

    It seems from my reading of research that about 75% of people have plantar plate tears but only a small percentage of those are painful. The definitive clinical test is a pain response at the base of the toe to plantarflexing the MPJ associated with the area of the symptoms. An effective treatment is to strap the toe to resist dorsiflexion moments. I use a loop of thin tubigauze around the toe, sandwich the loose end between two pieces of adhesive 2mm felt or fleecy web and tape the felt to the plantar mpj's while slightly plantarflexing the appropriate toe. (Ref Kevin Kirby for this advice that has worked well for me for many years) Show the patient how to refix it after bathing etc and keep the strapping in place for 2-3weeks. This often does the trick on its own but I usually add some orthoses in to the treatment program and mobilisation of the ankle joint to reduce forefoot plantar forces.

    Cheers Dave
     
  8. Thanks Dave I must admit most of my treatment process has come from the great man as well, but Ive missed the taping is my reading of Kevins posts. I´ll add it see whats happens, but having really good results with what Ive been doing so far which is good. In fact a patient with 7 years of pain just came in and said how great the last 4 days has been pain down 75%.

    As for the definitive clinical test thats under palpation section - same test for me as well.
     
  9. Plantar plate tears/capsulitis of the 2nd metatarsophalangeal joint (MPJ) is the second most common pathology I see in my practice currently, with first place going to plantar heel pain. In the lectures I give on this subject, I note that the cadaver research shows, like Dave said, that plantar plate tears are extremely common and most are asymptomatic. It is likely that the more severe the tear, the more the symptoms, and that small tears simply don't hurt enough to bring the patient into the clinic for examination.

    The plantar plate is a fibrocartilagenous shallow-cup-shaped structure that the lesser metatatarsal heads lie directly on and the plantar plate is also attached directly to the central component of the plantar aponeurosis and the base of the the proximal phalanx of the digit (by way of ligament). As such, the plantar plate will be subjected to significant compression and tensile stresses with each step and these compression and tensile stresses are the likely mechanical etiologies for this common injury of the human foot.

    Therefore, the plantarflexion taping of the digit which Dave mentioned will reduce the tension stresses on the plantar plate while accommodative padding/foot orthosis treatment of the affected MPJ will help reduce the compression stresses on the plantar plate. I combine these therapies with icing therapy, 20 minutes directly on the plantar foot, for 2-3 times a day, to reduce the plantar swelling which will also further reduce the compression force on the plantar plate. I also recommend avoidance of barefoot walking, recommend always walking with accommodation of the affected MPJ in shoes and, preferably, walking only with specially-modified custom foot orthoses under their feet. 90% of these injuries do not require surgery but the more persistent and severe cases may require lesser metatarsal osteotomies, hammertoe repairs or plantar plate repairs to resolve their symptoms. By the way, I don't standardly use ultrasound or MRI for diagnosing these problems, but, certainly would want an MRI scan done if direct surgical repair of the suspected plantar plate tear is being considered.

    BTW, Martin's previous postings on the benefit/utilility of diagnositic ultrasound have been very instructive to me as to the potential benefit of having a diagnostic ultrasound unit in my office at some point in time.

    Good discussion.:drinks
     
  10. RobinP

    RobinP Well-Known Member

    I'm sorry to take this discussion back a little but the paper attached by mike states that patients are presenting with 2nd metatarsal pain and hammer toe deformity. Is the plantar plate tear really that common that anyone presenting with lesser metatarsalgia, one of the differential diagnoses should be plantar plate tears?

    I only ask because until reading that paper I had no experience or knowledge of plantar plate tears - shamefully. That is why Podiatry Arena is so valuable as a resource.

    Thanks

    Robin
     
  11. David Smith

    David Smith Well-Known Member

    I would say Yes to the first question, but only using clinical tests. Secondly, the toe proximal phalanx can become subluxed on the met head when the plantar plate tears and one clinical test is to look for excessive dorsal float similar to the drawer test for knee for cruciate ligament injury.

    Cheers Dave
     
  12. G Flanagan

    G Flanagan Active Member

    Robin,

    i too always suspect involvement of the plantar plate in any pain presenting around the 2nd MTPj.

    I also find more often that the plantar plate is very rarely addressed surgically, even if involvement is suspected. Usually digital / met deformity correction is undertaken solely.

    However i'm not surprised you haven't heard of it prior as most pod's i speak to don't even know what the plantar plate is.

    I also lecture occasionally at one of the schools of podiatry (UK) and am astonished that no student i ask knows what the plantar plate is. For some reason it seems to just be missed out of anatomy teaching.
     
  13. RobinP

    RobinP Well-Known Member

    I'll be making a point in future to be aware of potential plantar plate tears.

    Thanks guys

    Robin
     
  14. bob

    bob Active Member

    No problem.

    That would be a good idea, although I guess there is variation within each country too (eg. USA state to state, UK podiatric surgery, etc..). Sorry to hear about the school closure in Sweden - I hope you guys get a new one opened and podiatry flourishes and that you can expand your practice as much as possible. Sorry to hear about orthopaedic problems as well, professional protectionism preventing preferrable patient payoffs par-chance?
     
  15. G Flanagan

    G Flanagan Active Member

    Bob i agree in regards of misdiagnosis on MR,

    Our local musculoskeletal radiologist (who is generally quite good), openly admits he finds it difficult to visualise on US and MR.
     
  16. RobinP

    RobinP Well-Known Member

    Hurrah - 2 months on from reading this thread, I have diagnosed my first plantar plate tear. It was missed by the orthopod and the US confirms.

    Stoked!

    Thanks for the information folks

    Robin
     
  17. Podiatry Arena Strikes again !!!!

    Good job that man
     
  18. dougpotter

    dougpotter Active Member

    Great information here Mr. Kirby!
     
  19. Thanks Mr. Potter!
     
  20. jrsenatore

    jrsenatore Member

    I, like Kevin, have found that a 2nd plantar plate tear or "pre-dislocation syndrome" falls just behind plantar fasciitis with visits to the office. This condition is also very common with runners. I have found using a Budin splint is usefull and an orthoses with a shaft pad and a 2mm raise at the distal edge of the device.
    Unfortunately, here in Baltimore, injecting the joint with cortisone is very common and that has often resulted in a complete rupture of the plantar plate in many athletes. A complete ruture of the plantar plate will cause a subluxed or dislocated joint. For these patients I usually do a Weil osteotomy with a fusion of the IPJ of a flexor to extensor transfer. What do others do with a subluxed or dislocated 2 mpj in a runner?

    John
    (kevin I want those pictures back!!!)
     
  21. gamilivi

    gamilivi Welcome New Poster

    I am a physiatry who works in Uruguay (South America)

    Could you explain the orthotics device for this pathology? and shoe customizations?

    .... and the biomechanical background to apply them

    Any images about orthotics devices to treat Plantar plate tear...

    Podiatry Arena is an excellent resource to me!!!!!


    Thanks to the great effort to the excellents discussants !!!!
     
  22. mimmypod

    mimmypod Member

     
  23.  

    Attached Files:

  24. mimmypod

    mimmypod Member

    Thank you Kevin :)

    Sorry for late reply. The diagrams look like you are plantar flexing the 2nd metatarsal head - is this correct?

    Big thank you,
    mimmypod
     
  25. These modifications reduce the ground reaction force plantar to the 2nd metatarsal head by accommodating it with padding at the metatarsal head level and also increase the ground reaction force on the metatarsal neck with the raised anterior edge of the orthosis.
     
  26. DaveJames

    DaveJames Active Member

    Hi Guys,

    Thanks for all the information regarding plantar plate tears. I'm pretty sure I've picked up one this morning on a patient with long standing 2nd MTP joint pain. Luckily I remembered some of the treatments you guys have recommended...

    On plantarflexion of the 2nd toe the patient remarked "that feels much better already". :D I've applied strapping and shown the patient how to re-apply it and will review in a few week

    A quick question - in your clinical experience, what sort of time would you expect symptoms to resolve?

    Kind regards,

    Dave
     
  27. Nice work Dave,

    It is one of those Depends ones. Sometimes short term with just tape etc , other orthotics and then others they move on to Surg consult.

    I always add icing, shoes which have less bend at the MTPJ as well as the tapeing for the 1st appointment .
     
  28. DaveJames

    DaveJames Active Member

    Cheers Mike,

    I had a feeling I was asking a "how long is a price of string" question; but I had to ask!

    I'm encouraged by the instant relief from the taping, and have got them to add ice to the area. Let's see what they say at review!

    Dave
     
  29. Griff

    Griff Moderator

    Hey Dave,

    My experience is that symptoms resolve almost immediately with taping, but as with most things that we tape they tend to slowly return within a day or two of its initial application.

    As such I tape these types of injuries less and less in the medium to long term, instead issuing orthoses with modifications such as Kevin has outlined in a previous post (particularly for those patients who put the kibosh on any surgical intervention). Complete symptom resolution is usually reported within a few weeks.

    IG
     
  30. DaveJames

    DaveJames Active Member

    Morning Ian,

    Thanks for the info. In this case, I get the feeling that surgery is not an option, therefore if the symptoms have not settled sufficiently upon review, then I will review the orthoses based on Kevin's recommendations.

    It's useful to have a backup plan and a rough timeframe when the patient asks about those things!

    Kind regards,

    Dave
     
  31. RobinP

    RobinP Well-Known Member

  32. anyone tried Kinesiotape for taping the toes to increase the dorsiflexion stiffness ?

    I am playing around with it seems good so far. n = 2 :eek:

    but it is an idea
     
  33. Tim VS

    Tim VS Active Member

    Not Kinesio, but I do use a strip of standard sports tape (leukotape) applied on the plantar aspect of the foot anterior to posterior along with the tape loop previously described. I have had fairly good results with this combination so far.
     
  34. DBWilloughby

    DBWilloughby Welcome New Poster

    Has anyone had any success with recommending a walking boot for about 6 weeks as part of conservative treatment?
    I have someone who says she is "ready to try anything to avoid surgery." We are currently icing, taping, using modified orthotics, only wearing stable running shoes, stretching, and attempting to limit use (she is a teacher who is on her feet all day and walks her dog 3x a day on short walks.)
     
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