Ultrasound of the plantar plate

NewsBot · Mar 23, 2006

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Sonography of Plantar Plates in Cadavers: Correlation with MRI and Histology
AJR 2006; 186:948-955

OBJECTIVE. The purpose of our study was to describe the sonographic appearance of the lesser metatarsal plantar plates in cadavers and to correlate these findings with MRI and histology.

MATERIALS AND METHODS. Six soft-embalmed cadaveric feet (74–92 years old; two male, one female) were imaged with sonography and MRI. Tear dimensions of the plantar plate were recorded in the long and short axes. Orthopedic surgeons directly inspected the plantar plates before removing samples for histologic correlation. One young fresh cadaver was imaged with sonography before histologic assessment.

RESULTS. The normal plantar plate appearance on sonography was a slightly echoic, homogeneous, curved structure. At direct inspection, a tear was present in 23 (96%) of 24 of the lesser plantar plates in the soft-embalmed feet. This direct inspection correlated with sonography detecting 23 tears correctly and MRI, 22 tears. Both sonography and MRI falsely reported one tear, but MRI also failed to detect one tear. Histologically, the abnormal plantar plate showed loss of the normal dense regular tissue and replacement with vessels, hydropic tissue, and a mixture of loose connective tissue and dense irregular connective tissue.

CONCLUSION. Sonography, being noninvasive, shows promise as an imaging tool of the plantar plate. With ongoing research in this area we hope to determine the reliability and significance of such a technique in the evaluation of the plantar plate.
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NewsBot · Jul 5, 2006

Ultrasound better than MRI

Sonographic and MRI evaluation of the plantar plate: a prospective study.
Eur Radiol. 2006 Jul 4;

The purpose of this study was to establish the accuracy of ultrasound in the examination of the plantar plate by comparing it with MRI, or if available, surgical findings. The lesser metatarsophalangeal joint plantar plates of 40 symptomatic and 40 asymptomatic feet (160 asymptomatic and 160 symptomatic plantar plates) were examined with ultrasound and MRI. Patients treated with surgery were chosen on a clinical basis and provided surgical correlation for the imaging techniques. Symptomatic patients with metatatarsalgia and suspected metatarsophalangeal joint instability were referred by an orthopedic foot specialist; asymptomatic feet were obtained either through examination of the contralateral foot of the symptomatic patients or volunteers. Ultrasound detected 75/160 and 139/160 plantar plates torn in the asymptomatic and symptomatic groups, respectively. MRI detected 56/160 and 142/160 tears in the symptomatic and asymptomatic groups, respectively. The sensitivity of MRI and ultrasound with surgical correlation was calculated to be 87 and 96%, respectively, with poor specificity. Ultrasound correlates moderately with MRI in the evaluation of the plantar plate. Surgical correlations, although limited (n=10), indicate ultrasound is superior to MRI with more accurate detection of tears.
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NewsBot · Sep 24, 2010

Plantar plate and second ray syndrome: Normal and pathological US imaging features and proposed US classification
Borne J, Bordet B, Fantino O, Bousquet JC, Coillard JY, Pialat JB.
J Radiol. 2010 May;91(5 Pt 1):543-8.

Second ray syndrome is due to degenerative changes of the plantar plate frequently associated to hallux valgus that may require dedicated surgical correction. An US classification is proposed and its impact on patient management is assessed. A total of 52 patients with hallux valgus and associated metatarsal pain scheduled for surgery were imaged. US resulted in modification of the treatment plan in 32% of patients. The surgical procedure was modified due to a plantar plate lesion not suspected on clinical and routine imaging findings. US improves the surgical management of patients with hallux valgus and second ray syndrome.
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NewsBot · Jul 23, 2013

Ultrasound Imaging for Diagnosis of Plantar Plate Ruptures of the Lesser Metatarsophalangeal Joints: A Retrospective Case Series
Russell M. Carlson, Katherine Dux, Rodney M. Stuck
The Journal of Foot and Ankle Surgery; 16 July 2013

Tears of the plantar plate can be a source of significant forefoot pain, leading to alterations of foot function and gait. The objective of the present retrospective study was to further determine the value of ultrasound imaging in diagnosing plantar plate tears after clinical evaluation through a comparison of the ultrasound and intraoperative examination findings. Eight patients were identified who had undergone surgical intervention for a painful lesser metatarsophalangeal joint after ultrasound examination to diagnose a plantar plate pathologic entity. The intraoperative examination findings were used to calculate the sensitivity, specificity, and positive and negative predictive values of ultrasound in the diagnosis of plantar plate tears. The sensitivity and specificity of the ultrasound examination was 1 and 0.6, respectively. The positive and negative predictive value was 0.6 and 1, respectively. An ultrasound examination in the diagnosis of lesser metatarsophalangeal joint plantar plate tears displayed comparable sensitivity in identifying the pathologic features when compared with magnetic resonance imaging, with considerably less financial cost for the examination.
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NewsBot · Jul 16, 2014

Static Versus Dynamic Musculoskeletal Ultrasound for Detection of Plantar Plate Pathology
Catherine A. Feuerstein, DPM; Lowell Weil Jr., DPM, MBA; Lowell Scott Weil Sr., DPM; Erin E. Klein, DPM, MS; Adam Fleischer, DPM, MPH; Nicholas G. Argerakis, DPM
Foot Ankle Spec August 2014 vol. 7 no. 4 259-265

Musculoskeletal ultrasound (US) is a common modality used to examine plantar plate pathology. Comparison of the diagnostic accuracy of static versus dynamic ultrasound has not been previously published. The objective of this study was to prospectively compare the value of using preoperative static and dynamic ultrasound findings to diagnose plantar plate pathology using intraoperative inspection as the standard of reference. Patients attending a single foot and ankle specialty clinic from August 2012 to June 2013 with clinically suspected plantar plate pathology that was unresponsive to conservative care served as the study population. Static and dynamic ultrasound exams were performed by a single experienced rater and compared to intraoperative findings. The overall accuracy, sensitivity, specificity, positive predictive value and negative predictive value were determined for static and dynamic ultrasound exams. Thirty-six patients (45 lesser metatarsophalangeal joints) were included in this analysis. Of the 36 patients, 29 were females and 7 were males with average age of 57.9 ± 7.8 years (range, 38-73). There were 38 plantar plate tears (84.4%) noted on intraoperative examination. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for the static US exam were 80.0%, 81.6%, 71.4%, 93.9%, and 41.7%, respectively. The same values for the dynamic US exam were 88.9%, 100%, 28.6%, 88.3%, and 100%, respectively. Static and dynamic ultrasound techniques are each highly sensitive methods for assessing plantar plate pathology. However, the sensitivity and accuracy of the exam is best when dynamic assessment of the plantar plate is employed. Caution should be used when relying solely on static images to diagnose subtle injuries in this area of the foot.
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NewsBot · Nov 22, 2014

Plantar plate imaging: correlating ultrasound arthrography and surgical findings
J. Viner, R. Jugdey, S. Khan, A. Zubairy and J. Barrie
Bone Joint J 2014 vol. 96-B no. SUPP 17 21

Introduction: Instability and synovitis of the lesser metatarsalphalangeal (MTP) joints is a significant cause of forefoot pain. Plantar plate imaging traditionally has been through MRI and fluoroscopic arthrography. We have described ultrasound arthrography as a less resource-intensive technique without radiation exposure. We report the correlation between ultrasound arthographic and surgical findings.

Methods: Patients with lesser MTP joint instability and pain underwent ultrasound arthrography by a consultant musculoskeletal radiologist. The main finding was the presence of a full or partial tear of the plantar plate. In some patients the location of the tear along with its size in the long and short axis was also reported.

Authors who were not involved in the imaging or surgery reviewed the operation notes of patients who underwent surgery to identify

Whether a partial or full thickness tear was identified

Size and location of the tear

The accuracy of ultrasound arthrography was calculated using surgical findings as the standard.

Results: 53 patients with 55 joints underwent ultrasound arthrography, and of these 34 went on to have surgery. 23 patients had adequate documentation of surgical and ultrasound findings. Surgery confirmed plantar plate tears in 21 patients (91.3%) with 9 full thickness tears and 7 partial thickness tears confirmed both operatively and with ultrasound (in 5 patients the operation note did not specify completeness of tear). In 2 patients, in whom ultrasound demonstrated a partial thickness tear, no tear was found at surgery. The sensitivity of ultrasound arthrography for plantar plate tears is 100%, specificity is 0% (although based on few patients), and positive predictive value of 91.3%.

Conclusion: Ultrasound arthrography has a high sensitivity, but low specificity for plantar plate tears, comparable with ultrasound in previous studies. It allows differentiation of partial and full thickness tears which may be important for treatment.
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NewsBot · Feb 20, 2016

Evaluation of lesser metatarsophalangeal joint plantar plate tears with contrast-enhanced and fat-suppressed MRI.
Dino? V et al
Skeletal Radiol. 2016 Feb 18

OBJECTIVE:
To present findings of plantar plate (PP) lesions from MRI with administration of gadolinium and to differentiate PP lesions from others causes of metatarsalgia.
MATERIALS AND METHODS:
Two musculoskeletal radiologists reviewed 249 contrast-enhanced forefoot MRI scans from patients with metatarsalgia between June 2012 and June 2013. Evaluations focused on hyper-vascularized/fibrous tissue and other findings associated with PP tears.
RESULTS:
Fifty-nine patients had PP tears, 59 % were female. Most of these patients, 48/59 (81.4 %), had a single metatarsophalangeal (MTP) PP lesion in one foot, although 7/59 patients had one lesion in each foot, 3/59 (5.1 %) had two in one foot, and 1/59 (1.7 %) had three lesions in one foot. The second MTP joint was the most common location for PP tears (n = 56), followed by the third (n = 12) and fourth (n = 3) MTP joints. Lateral (n = 33) and full thickness (n = 28) PP lesions were the most frequent, and central (n = 3) and lateral/central (n = 7) tears were less prevalent. Fifty (70.5 %) PP lesions showed pericapsular fibrosis in pre-contrast sequences, and 21 (29.5 %) were visible only after administration of gadolinium. All PP lesions had collateral ligament involvement. Others findings included interosseous tendon lesions (n = 29), interosseous tendon rupture (n = 29), synovitis (n = 49), flexor tenosynovitis (n = 28), crossover toe (n = 2), hammertoe (n = 1), intermetatarsal space (IS) neuromas (n = 11), and third IS neuromas (n = 12).
CONCLUSION:
PP tears are a common cause of metatarsalgia, accounting for more than 20 % of cases in our sample. A substantial portion of the lesions (29.5 %) became visible only after the administration of gadolinium.
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NewsBot · Apr 12, 2017

Accuracy of Sonography in Plantar Plate Tears in Cadavers.
Stone M et al
J Ultrasound Med. 2017 Apr 11. doi: 10.7863/ultra.16.06067

OBJECTIVES:
Sonography is often used in the evaluation of forefoot disorders, and its use has been suggested in the diagnosis of plantar plate tears. This study aimed to assess the accuracy of sonography in the diagnosis of plantar plate tears of the lesser digits using gross dissection as the reference standard.
METHODS:
The second through fifth digits of 6 cadavers were examined with sonography to evaluate for plantar plate tears. The examination was performed by a single musculoskeletal radiologist in longitudinal and short axes, and plates were graded as torn or intact. The digits were then dissected by a single podiatrist blinded to the prior sonographic results to assess the integrity of the plates.
RESULTS:
Ten plantar plates were graded as torn by sonography, all occurring in the distal plate near the phalangeal insertion. Seven of these plates were identified as torn on direct inspection. Fourteen plantar plates were found to be intact on sonography, 12 of which were intact on gross inspection. Overall, the accuracy, sensitivity, and specificity of sonography were 79.2%, 77.8%, and 80.0%, respectively. No correlation was seen between the accuracy of sonography and plate size, using plate number as a surrogate marker for plate size (P = .822).
CONCLUSIONS:
Sonography is an appropriate modality in the setting of suspected plantar plate tears, with acceptable accuracy, sensitivity, and specificity. No decline in accuracy was seen with smaller plates. Thus, sonography may be especially useful when small anatomy or technical factors make magnetic resonance imaging challenging to perform and interpret.
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