The human foot is a marvel of nature. Its complex anatomy allows us to stand, walk and run. With all the strain we put on it, it is not surprising that feet issues might occur.
A commonly missed and underdiagnosed injury of the foot includes plantar plate tears. These lead to significant discomfort in the ball of the foot. In this piece we will explore the causes, symptoms and treatment options for plantar plate tears, offering useful insight to help keep your feet healthy and pain-free.
The Anatomy of the Plantar Plate
Before diving into the specifics of plantar plate tears, let's first go over their basic anatomy. Plantar plate is a fibrocartilagenous structure located under the ball of the foot, connecting base of the toe to the metatarsal behind the joint, keeping them in the correct position. It also plays a key role in maintaining stability within the metatarsophalangeal (MTP) joint.  It also acts as an attachment site for the plantar fascia, and is involved in the windlass mechanism.
Fig 1: Windlass Mechanism - Physiopedia
What is a Plantar Plate Tear?
One of the main causes of plantar plate tears is overuse and repetitive strain, such as in athletes engaged in sports such as sprinting and jumping, leading to microtrauma and eventually plantar plate tear, manifesting as discomfort in the ball of the foot characterized as a feeling of "walking on bones." In essence, repetitive and excessive dorsiflexion activities at the metatarsal-phalangeal joint (MTPJ) can increased joint forces and overload.
People who have existing foot abnormalities, such as flat feet, hammertoes, or bunions (hallux valgus), are more likely to develop a plantar plate rupture. Bunions cause aberrant foot-loading patterns, which contribute to recurrent injuries to the second toe and plantar plate tears. Directly stubbing the toe due to a fall or a heavy object falling on the foot might result in acute trauma and structural alterations such as a plantar plate rupture. Women who wear high-heeled shoes frequently are also at risk of developing a plantar plate tear due to the vertical strain exerted on the second toe.
Additionally, as the body's tissues undergo natural changes during the ageing process, changes to the plantar plate tissue structure can lead to potential weakness and injury.
How is a Plantar Plate Tear Diagnosed?
Detecting plantar plate tears in their early stages is important to prevent its complications. Plantar plate tears result in a multitude of symptoms. The most characteristic is long-term foot pain under the ball of the foot. In fact, a recent study suggested that plantar plate tears were found in 40% patients with chronic metatarsalgia (long-term foot pain) . Other symptoms include swelling, instability and an abnormal rotated or raised appearance of the toe (Churchill sign).
The confirmatory gold standard test for Plantar Plate tear is an MRI (Magnetic Resonance Imaging), as research indicated it to be the most sensitive and specific . That said, ultrasound or X-ray may also be used. Researchers have identified and described findings that confirm the tear i.e. presence of pericapsular fibrosis which is found in 98% of the cases. 
Road to Recovery - How are Plantar Plate Tears Treated?
The first approach after confirmation of the diagnosis is alleviation of symptoms. Patients are advised to rest their feet, by reducing or modifying physical activity allowing the plantar plate to heal.
No barefoot walking
Cold compresses of the affected area for 20 minutes each, several times daily can aid to reduce pain and inflammation.
Supportive Orthotic footwear is recommended to minimize the pressure exerted on the feet, reducing strain on the already injured plantar plate tear. An air cast boot may also be used to offload the MTPJ
Strapping can be effective in reducing plantar plate load (placing second toe into plantarflexion)
Steroid injection may also be used in some cases, however caution is advised as injections may reduce the structural strength of ligamentous tissue, potentially increasing the risk of future rupture.
In a case report study, conservative treatment resulted in fill restoration of function and radiological evidence of healing at 12 months post injury.  In chronic cases where conservative treatments are unsuccessful, a surgical approach may be required. In a recent study published in 2022, arthroscopic repair of plantar plate tears showed resulted in a high rate of return to activity/sport within 6 months. 
Fig 2: Second toe plantarflexion taping - https://ijspt.scholasticahq.com/article/30021-forefoot-injuries-in-athletes-integration-of-the-movement-system
Injury Prevention - Avoiding Plantar Plate Injury
Prevention is better than cure. It’s better to take measures to avoid plantar plate tears altogether especially if you are at a higher risk due to the factors mentioned above. For example, if you have foot abnormalities like hammer toes or bunions, have them checked and treated by a podiatrist. An adequate warm up and wearing supportive footwear can help reduce the risk of plantar plate tears.
Plantar plate tears can cause severe discomfort and mobility problems for the foot complex, resulting in reduced function. Understanding its cause, symptoms, and treatment choices is helpful to keep your feet healthy and happy! Early identification and adequate treatment can assist to reduce the risk of injury.
Don't forget that your feet are the foundation of your movement! If you believe you have a plantar plate tear or are experiencing foot pain, book in today for an in depth physiotherapy consultation.
Shilpa Jha, Callum Clark,Plantar plate rupture: aetiology, diagnosis and treatment,Orthopaedics and Trauma,Volume 37, Issue 1,2023,Pages 28-33,ISSN 1877-1327
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Jordan, M., Thomas, M., & Fischer, W. (2017). Nonoperative Treatment of a Lesser Toe Plantar Plate Tear with Serial MRI Follow-up: A Case Report. The Journal of Foot and Ankle Surgery, 56(4), 857–861. doi:10.1053/j.jfas.2017.02.016
Husebye EE, Stødle AH. Arthroscopic Repair of Chronic Plantar Plate Tears of the First Metatarsophalangeal Joint: A New Surgical Technique With Patient Outcomes. Orthopaedic Journal of Sports Medicine. 2022;10(12). doi:10.1177/23259671221137558
Disclaimer: This blog is for informational purposes and should not be considered a substitute for professional medical advice. Please consult with our qualified healthcare providers for personalised recommendations related to your specific condition and needs.