Plantar Plate Provocation Test

NewsBot · Jun 26, 2014

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Plantar Plate Provocation Test
A Clinical Sign for Identification of Plantar Plate Lesion
Jose Antônio Veiga Sanhudo
Foot Ankle Spec June 24, 2014 1938640014539809

“In view of their similar histories and location of symptoms, plantar plate lesions are often difficult to distinguish from Morton’s neuropathy . . .”
Plantar plate lesions are being increasingly identified due to heightened clinical suspicion, thorough physical examination, and advances in medical imaging, particularly in magnetic resonance imaging (MRI) techniques.1⇓⇓⇓-5 By virtue of their anatomic proximity, plantar plate lesions are often mistaken for Morton’s neuropathy, and as the treatment of these entities is quite different, accurate differential diagnosis is paramount. Furthermore, both lesions may occur concomitantly, and surgical treatment of only one condition will lead to only partial improvement of symptoms. This report describes a clinical finding that can …
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William Fowler · Jun 26, 2014

Can anyone with access to the publication tell us what the test is?

Craig Payne · Jun 26, 2014

I just googled to see what it was. This thread came out ranked first on Google for "Plantar Plate Provocation Test"

MischaK · Jun 26, 2014

William Fowler said: ↑

Can anyone with access to the publication tell us what the test is?
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Sanhudo (2014, pp. 1-2) describes the plantar provocation test as follows:

With the patient in a seated position and the affected foot hanging free or supported by the examiner’s knee, the midfoot is grasped with one hand while the other hand grasps the desired toe so that the examiner’s index finger is placed over the dorsal base of the proximal phalanx. The examiner then applies moderate dorsiflexion while pushing the phalanx in the plantar direction, thus tensioning the plantar plate. If pain is elicited in the plantar region of the metatarsophalangeal joint, despite no pressure being applied on the joint itself, the test is positive.
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Sanhudo, J.A.V. (2014). Plantar plate provocation test: A clinical sign for identification of plantar plate lesion. Foot & Ankle Specialist. doi: 10.1177/1938640014539809

Griff · Jun 26, 2014

From the paper also:

mike weber · Jun 26, 2014

Good to see I have been using the test correctly for the last few years then

Admin2 · Jun 27, 2014

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NewsBot · Sep 20, 2014

Positive Drawer Test Combined With Radiographic Deviation of the Third Metatarsophalangeal Joint Suggests High Grade Tear of the Second Metatarsophalangeal Joint Plantar Plate
Erin E. Klein, DPM, MS; Lowell Weil Jr, DPM, MBA; Lowell Scott Weil Sr, DPM; Michael Bowen, DPM
Adam E. Fleischer, DPM, MPH
Foot Ankle Spec September 18, 2014

There is uncertainty regarding the most accurate and cost-effective method for diagnosing plantar plate injuries within the foot. The purpose of this study was to examine the combined value of using clinical and radiographic findings to diagnose high grade tears (> 50% disruption) within the second metatarsophalangeal (MTP) joint. Ninety-eight consecutive patients (117 feet) who underwent corrective surgery for plantar forefoot pain at a single foot and ankle specialty clinic were included in this retrospective analysis. All patients received a structured intraoperative assessment of the second MTP joint plantar plate by a single trained observer. Twenty-five clinical and plain film radiographic variables obtained prior to surgery were tested for their association with a high grade plantar plate tear using multiple logistic regression techniques. A positive drawer sign was the most informative individual test for differentiating high from low grade tears (odds ratio [OR] = 2.9; 95% confidence interval [CI], 0.92-9.5; sensitivity 91.5%; specificity 22%). Patients with longstanding forefoot symptoms (> 2 years) tended to be more likely to have low grade tears only (OR = 2.1; 95% CI, 0.98-4.5; sensitivity 61.7%; specificity 58.1%). Most radiographic measurements did little to distinguish high from low grade tears; however, the addition of ipsilateral third MTP joint transverse deviation angle showed a trend toward improving upon the diagnostic accuracy of strategies that used clinical findings alone (area under the curve [AUC] improved from 0.63 to 0.67; P = .11). A third MTP joint deviation angle greater than 15° in either direction combined with drawer testing and duration of symptoms achieved the highest specificities of any combination of variables examined in the study (specificities 82.4% [95% CI, 73.7%-91.1%] and 89.1 [95% CI, 82.1-96.3], respectively). The combination of a positive drawer test coupled with transverse deviation of the third MTP joint (> 15°) on plain films strongly suggests an underlying high grade plantar plate tear of the second MTP joint. However, this study highlights the need for using advanced imaging to distinguish between high and low grade tears in many instances (eg, positive drawer test and normal or near-normal alignment of the third MTP joint).
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NewsBot · Dec 20, 2014

Can ultrasound of plantar plate have normal appearance with a positive drawer test?
Eloy de Ávila Fernandes, Tania Szejnfeld Mann, Andrea Puchnick, Franklin de Freitas Tertulino, Camila Testoni Cannato, Caio Nery, Artur da Roch Corrêa Fernandes
European Journal of Radiology; 15 December 2014

Highlights
•We evaluate the accuracy of ultrasound to identify and measure the plantar plate.
•We correlate ultrasound findings with those of physical examination and MRI.
•Ultrasound and MRI measures of plantar plate were positively correlated.
•Ultrasound is efficient in identifying and measuring plantar plate.
•Ultrasound may complement physical examination.
•Young asymptomatic subjects can present a grade I positive drawer test.
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Objectives
The aims of this study were (1) to evaluate the reliability of ultrasound (US) examination in the identification and measurement of the metatarsophalangeal plantar plate (MTP-PP) in asymptomatic subjects and (2) to establish the correlation of US findings with those of physical examination and magnetic resonance imaging (MRI), once it is an important tool in the evaluation of the instability syndrome of the second and third rays.

Materials and Methods
US examinations of the second and third MTP-PPs were performed in eight asymptomatic volunteers, totaling 32 MTP joints, by three examiners with different levels of experience in musculoskeletal US. Plantar plate dimensions, integrity and echogenicity, the presence of ruptures, and confidence level in terms of structure identification were determined using conventional US. Vascular flow was assessed using power Doppler.US data were correlated with data from physical examination and MRI.

Results
MTP-PPs were ultrasonographically identified in 100% of cases, always showing homogeneous hyperechoic features and no detectable vascular flow on power Doppler, with 100% certainty in identification for all examiners. There was excellent US inter-observer agreement for longitudinal measures of second and third toe MTP-PPs and for transverse measures of the second toe MTP-PP. The MTP drawer test was positive for grade 1 MTP instability in 34.4% of joints with normal US results. Transverse MTP-PP measures were significantly higher in individuals with positive MTP drawer test. US measures and characteristics of MPT-PPs were positively correlated with those of MRI.

Conclusions
US is efficient in identifying and measuring MPT-PPs and may complement physical examination. A grade 1 positive MTP drawer test may be found in asymptomatic individuals with normal MPT-PPs, as assessed by imaging.
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NewsBot · Nov 20, 2018

Use of Metatarsophalangeal Joint Dorsal Subluxation in the Diagnosis of Plantar Plate Rupture
Marie-ChristineBergeron et al
The Journal of Foot and Ankle Surgery; 15 November 2018

A dorsal drawer exam, also known as a modified Lachman's test, is a common clinical test for plantar plate insufficiency. This disorder presents as a dislocated metatarsophalangeal joint. The aim of this cadaveric case study was to quantify the degree of the plantar plate pathology necessary to correlate with a positive Lachman's test. The second metatarsophalangeal joint was tested on 18 cadaveric lower extremities. Limbs with previous digital surgery or with an obvious digital deformity were excluded from this study. A plantar linear incision over the plantar aspect of the second metatarsophalangeal joint was performed, and the flexor tendons were retracted to expose the plantar plate. After evaluating the plantar plate's integrity and measuring its width, a Lachman's test was then performed under fluoroscopy. The plantar plate was subsequently severed in a serial manner in 2-mm increments. A modified Lachman's test was performed with the different levels of rupture to assess the degree of dislocation. We found that a tear as small as 2 mm, detected in 12 (66.7%) of 18 specimens, produced gross instability in the second metatarsophalangeal joint. We also showed that a simulated plantar plate tear ≥4 mm but <6 mm resulted in joint subluxation (positive modified Lachman's test) with a sensitivity of 90.3%. This study reinforces the finding that a modified Lachman's test is a clinical exam that demonstrates high sensitivity in diagnosing plantar plate insufficiency.
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