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Plantar plate pathology incidence

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Robertisaacs, Oct 24, 2009.

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    Hey all.

    Been meaning to put this one up for a while. Kept Forgetting.

    I was reading some stuff on Mortons Neuroma the other week. Specifically it was questioning the use of Steroid injection without a firm diagnosis, hypothesising that if it was in fact a plantar plate pathology it could cause / worsen a tear.

    Now when I did my degree (which I admit was a few years back now), we covered plantar plate pathology in precisely 0 lectures. Since then, I've worked closely with 3 Podiatric surgeons and done about 7 years of FULL TIME biomechanics. During that time I've seen plantar plate tear reported / diagnosed approximatly 0 times, had 0 referrals for it, and seen around 0 patients who have had plantar plate repairs.

    And yet, without much effort, I have found large quantities of literature on its diagnosis, and surgical repair which talks as if its as common as mud!

    Is this just me? Is it a Kent thing, that all the plantar plate pathology is further North? Or is it a UK / US thing?

    I do notice that diagnosis seems to be mainly by imaging, is this to do with the relatively poor availability of imaging diagnostics in the UK? My merrie band of surgeons cheerfully whip out interdigital nerves without anything more than a clinical diagnosis but I know thats not the same everywhere!

    How many plantar plate cases do you see? What is the incidence? And can a steroid injection administered for a neuroma cause harm?

  2. Ryan McCallum

    Ryan McCallum Active Member

    Hi Robert,
    this is also a subject I have thought about. I definitely don't remember covering it in university and I'm not sure I saw any plantar plate tears until i moved to London 2 years ago (so maybe the pathology is location specific!). Thinking back, I am sure I did and just didn't really think too much about i
    I work full time in a surgical unit and see a fair few plantar plate tears. Maybe 2 per week out of about 120-130 patients. The vast majority of plantar plate tears I see are in conjunction with hallux valgus deformities (either severe or recurrence deformities where the 1st met has been shortened or elevated significantly.)

    As for diagnosis, I always basis my diagnosis on clinical examination. I have never requested imaging for a suspected plantar plate tear.

    As for injection of neuromas, I inject these almost on a daily basis and don't think I have ever seen any resultant plantar plate tears from these. I have however injected a small number of 2nd MTPJs for 2nd MTPJ synovitis cases to see the patient returning a couple of months later complaining that their toe was now hammered and clinically, was easily manipulated into a dorsally subluxed position at the MTPJ! I don't know if in theses cases, the steroid causes the tear, speeds up the process or whether the plantar plate would have torn anyway.

    Generally, we repair plantar plate tears if the patient doesn't respond to conservative care and in the last 3 months, we have maybe done 5 or so repairs.

  3. Plantar plate pathology is quite common, and most plantar plate tears are likely asymptomatic.

    Here are some nice articles for those of you who are interested in learning more about this important structure within the human foot.

    Deland JT, Lee KT, Sobel M, DiCarlo EF: Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint. Foot Ankle Int., 16:480-486, 1995.

    Yu GV, Judge MS, Hudson JR, Seidelmann FE: Predislocation syndrome: Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. JAPMA, 92: 182-199, 2002.

    Blitz NM, Ford LA, Christensen JC. Plantar plate repair of the second metatarsophalangeal joint: Technique and tips. JCFAS, 43:266-270, 2004.

    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.

    Gregg JM, Silberstein M, Schneider T, Marks P: Sonographic and MRI evaluation of the plantar plate: a prospective study. European Radiology, 16:948-955, 2006.

    Gregg J, Marks P, Silberstein M, Schneider T, Kerr J: Histologic anatomy of the lesser metatarsophalangeal joint plantar plate. Surgical Radiol Anat, 29:141-147, 2007
  4. Lee

    Lee Active Member

    Hello Robert,

    Echoing Ryan and Kevin's posts, I see my share of these. As Ryan has said, they often accompany hallux valgus. Along with clinical signs (Lachman's, often transverse and sagittal displacement of the proximal phalanx and pain on direct pressure to the plantar aspect of the joint) and symptoms ("walking on a marble" is a common complaint), I like a picture to back up the diagnosis - Ultrasound or MRI depending on local facilities. This helps when differentiating neuroma/capsulitis/plantar plate tear.

    Over the last month or so, there have been a lot of patients presenting with plantar plate tears. I operated on a lady last week who had a huge tear at the plantar aspect of the 2nd MTPJ - biggest I've seen. Following repair of the defect, the consultant that I work for showed me a nice technique for reefing the slack flexor tendons. I did this and fused the PIPJ to stabilise the toe.

    There's probably a lot of plantar plate tears out there that have gone undiagnosed. I suspect that many severe hammer toe deformities we see may have started out as plantar plate tears, especially in the presence of hallux valgus. I've got some plantar plate repairs on my list in the next couple of months, so if you'd like to see one just PM me on here and I'm sure we can sort out a trip to Norfolk for you.

    Have a good one,

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