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Running Injuries Plantar Plate Sprains and Plantar Plate Tears

Plantar Plate Sprains and Plantar Plate Tears

What Are Plantar Plate Sprains?

Plantar Plate sprains are a common disorder that affects runners of all ages and run all distances.  Runners will typically describe intense pain near their 2nd through 4th toes in the ball of the foot that gets worse while walking or running. Read on for more information, or see our Plantar Plate Sprain Overview.

Video on Plantar Plate Sprains – 3 Minutes

Typical Plantar Plate Sprain Scenario

A typical scenario that occurs will be for the runner to ask their running buddies what to do about the pain.  Frequently they are given advice that leads them down a path of frustration and more pain.  They try icing their foot and taking Ibuprofen most commonly.  Sometimes the runner consults their primary care doctor who simply tells them to stop running or may refer them to a foot specialist.  Once at the foot specialist they may receive one of many incorrect diagnosis.

Common Plantar Plate Sprain Misdiagnoses

Plantar plate sprains and tears are often misdiagnosed. Compare similar running injuries and conditions, plus learn how to differentiate between each.

Morton’s Neuroma

The most common misdiagnosis is Morton’s Neuroma.  This condition is confused with a Plantar Plate sprain because both injuries can result in burning pain that shoots into the affected toes.  If this incorrect diagnosis is given the specialist may inject the area with cortisone with little to no affect.  Differentiating these conditions is actually quite simple with proper manual, orthopedic testing.  If there is still doubt after a thorough examination an MRI can be used to differentiate the disorders.  San Diego Running Institute has brokered cash deals with private, local San Diego MRI facilities for those that have either no MRI coverage or catastrophic deductibles that often prevent them from obtaining proper care or treatment.  The average cash fee for an MRI is only $400.

Metatarsal Stress Fracture

Another common misdiagnosis is a Metatarsal Stress Fracture.  While Metatarsal Stress Fractures do occur they are over diagnosed.  Metatarsal Stress Fractures are confused with Plantar Plate sprains because the Metatarsal bone can fracture at the Metatarsal Neck which is close to the Plantar Plate.  In addition both injuries can cause the person to limp even when not running.  These two injuries can usually be differentiated with a proper and thorough orthopedic exam.  If there is still doubt as to the true nature of the injury an X-ray or MRI can be used to provide a complete and accurate diagnosis.

X-rays can be performed the same day as the examination and do not require a scheduled appointment whereas an MRI can usually be performed within a couple of days.

Sesamoiditis

Sesamoiditis is another condition I have seen diagnosed incorrectly over a Plantar Plate sprain.  Sesamoiditis is a painful condition that affects the Sesamoid bones found under the First Metatarsal.  This condition is easily and quickly differentiated from a Plantar Plate sprain due to where it is anatomically located.

Interdigital Bursitis

I have also seen Interdigital Bursitis misdiagnosed as a Plantar Plate sprain.  This painful condition is characterized by pain found between the Metatarsal bones instead of beneath the Metatarsal bones.  During a proper orthopedic examination this condition is identified by pressing the softer region between the Metatarsal bones.  If localized pain is present you may be suffering from Interdigital Bursitis.

Frequently Asked Questions (FAQs): Plantar Plate Sprains

Here are my answers to questions that patients often ask about plantar plate sprains. If you would like to make an appointment call (858) 268-8525.

What Are Grade 1, Grade 2, & Grade 3 Plantar Plate Sprains?

A sprain is a torn ligament.  Sprains occur in varying degrees of severity.  A Grade 1 Sprain describes a ligament that was overstretched which results in microtears and ligament laxity.  A Grade 2 Sprain is defined by partial tearing of the ligament resulting in more severe pain and possibly, partial joint deformity.  A Grade 3 Sprain is a complete tear of the ligament and results in intense pain with obvious joint deformity.  Since Plantar Plate Sprains come in varying degrees they are sometimes difficult for doctors who do not specialize in diagnosis and treatment of the disorder to identify and diagnose accurately.

How Do I Know if I Have a Torn Plantar Plate?

If you have pain beneath your 2nd, 3rd or 4th metatarsal that gets worse with walking, jumping or running you may have a Plantar Plate Sprain.  In the early stages of the injury it is most likely a Grade 1 Plantar Plate Sprain and can be treated quickly and effectively with conservative methods.  You will know if the injury has progressed if your pain gets worse or you develop a limp following activity.  Dr. Runco and the San Diego Running Institute can perform a thorough orthopedic examination of your foot to accurately diagnose the condition and differentiate it from other conditions such as Metatarsalgia, Metatarsal Stress fracture, Interdigital Bursitis, Morton’s Neuroma and Sesamoiditis.

How Do I Fix My Torn/Sprained Plantar Plate Ligament?

Depending on the severity of the tear depends on the course of treatment that will be effective. Some common treatment suggestions include:

  • Stop running until it heals
  • Plantar plate supports on insoles of shoes
  • Waterproof athletic tape
  • Therapeutic Ultrasound
  • Simple exercise
  • Stiff bottom walking boot
  • Surgery (last resort!)

Grade 1 and Grade 2 Plantar Plate Sprains are treated with excellent outcomes at the San Diego Running Institute.  Grade 3 Plantar Plate Sprains are more severe and will not typically respond to conservative treatment and may require surgery.  While I never desire to tell a runner to “Stop running”, that is exactly what I have to do in most cases of a Plantar Plate Sprain.

In mild cases we successfully treat the condition by placing Plantar Plate supports on the runner’s insoles of the shoes they wear most often.  We also use waterproof athletic tape to align the joint to ensure maximum and effective healing.  Therapeutic Ultrasound is applied to stimulate blood flow into the largely avasucular Plantar Plate Ligament.  Simple exercises are prescribed to stimulate blood flow and promote strengthening of the deep intrinsic muscles of the foot.

Severe Grade 1 sprains and Grade 2 Plantar Plate Sprains usually require me to prescribe a stiff bottom walking boot for the runner to wear for six to twelve weeks depending on the severity of the sprain.  This ensures that the patient is not flexing, bending or stretching the damaged Plantar Plate and allows for maximum and complete healing.  During the time period the patient is required to wear the boot a therapeutic protocol consisting of Ultrasound, taping and exercises is also undertaken.

Do I Need Plantar Plate Surgery?

Only after failing conservative therapy should surgery be considered.  While surgery is an option is should be your last resort in most cases.  It is my experience that 90% of patients I treat with conservative methods do not require surgery and return to normal, pain free running.

Do I Need Custom Orthotics For My Torn Plantar Plate?

While custom orthotics are a common intervention in the treatment of Plantar Plate Sprains they are not a panacea.  If the custom orthotic is not crafted correctly, if the plantar plate support is not placed precisely and if the injury is not addressed and given time to begin the healing process than the custom orthotic will most likely be ineffective.  It is my experience that after the injury is healed and the person resumes normal pain free activity a custom orthotic can be made to prevent future reoccurrences of the injury.  San Diego Running Institute makes our own custom orthotics on site which helps keep the costs below average ($247) and gives us complete control in the construction of the orthotic.  It has been my experience in the past that orthotic labs create hard, rigid orthotics that actually make the condition worse.

Will My Plantar Plate Tear Heal 100%?

If all of the correct procedures are followed there is no reason to expect anything less than 100% resolution of the condition.  By supporting and/or immobilizing the Plantar Plate, usually for a period of 6 weeks to 3 months, the ligament will heal by forming new tissue know as Fibrin.  The new fibrotic tissue will essentially from a “patch” over the damaged area of the Plantar Plate.  This new fibrotic tissue will at first be stiffer and may result in feelings of “tightness” beneath the Metatarsals.  Over the period of the next few months, even up to a year, the feelings of stiffness and tightness will lessen due to specialized cells in your body called Macrophages.  These cells will reshape and reorganize the fibrotic tissue molding it as close to perfect as possible.   It is my experience that making custom insoles with Plantar Plate supports provides additional protection to the area while it undergoes remodeling and strengthening and are a viable addition in the prevention of future reoccurrences.

My Personal Experience as a Marathon Runner with a Sprained Plantar Plate

As a competitive Ultra Marathon runner I understand the importance and significance of running.  It is our “yoga”.  I completely understand how a runner can rationalize running with a painful condition such as a Sprained Plantar Plate.  I know because I did it.  I ran with a painful and sore 2nd metatarsal for months.  The injury did not appear to be worsening so I continued to run on it until one day it went from bad to worse…..in an instant.  That day it progressed from a Grade 1 Sprain to a Grade 2 Sprain/tear.  The pain was intense and caused me to limp.  An MRI confirmed the extent of the tear.  I ended up in a walking boot for almost 3 months as well as receiving Ultrasound therapy every other day in my own clinic.  After five months I was back to running significant distance and at month eleven I ran a 50K, setting a personal best.  Because I suffered from this injury I have empathy for those that suffer from it and have developed a deep passion for helping others correct it in addition to becoming an expert in the treatment of it.

Be sure to read the comments for patient questions and my personalized responses about plantar plate sprains, tears, and injuries.

About Victor Runco

Dr. Runco is a U.S. Navy and Gulf War Veteran. Graduating as a Doctor of Chiropractic he began private practice in San Diego in 2000. He has been a professor of Anatomy, Physiology, and Biomechanics at various colleges and continues to teach continuing education in the fields of rehabilitation, custom orthotics and athletic taping. He is also a member of the American College of Sports Medicine, National Strength and Conditioning Association and is a Certified Strength and Conditioning Specialist. He has completed over 15 Marathons in 15 states and has run 9 50 mile Ultramarathons.

Comments

Dr. Runco 09-03-2015, 21:59

Marie I would recommend you schedule a phone consult by calling 858-268-8525. On our phone call I will provide you with detail of how to correct this injury the right away and avoid surgery. I will also email you a written treatment plan that is very specific as to what should and should not be done. Right now your gut is telling you the PT is not right….you should listen to your gut. Stretching the toes back toward the top of your foot to increase range of motion could quite possibly be tearing your plantar plate further.

Jason 19-04-2015, 01:53

Mr Runco, frankly I believe that one should not take any risks and directly go for surgery if he/she gets a severely torn plantar plate as in such a case one may risk losing his/her leg if appropriate measures are not taken. Yes, in case of a minor tear your suggested steps apply perfectly well.

Dr. Runco 20-04-2015, 09:40

Jason what is a “seveely” torn plantar plate in your opinion. Tears come in many varieties
Grade 1 – rarely requires surgery if treated appropriately
Grade 2 – Partial tear. May require surgery but if treated early in the process it demonstrates the ability to heal well. I know this because I suffered a partial rupture and healed perfectly in 4 months. I have run multiple 50 mile events since then and my foot is fine. I have been successful in helping hundreds of others do the same
Grade 3 – full tear or rupture. Will usually require surgery and I almost always advise it in this instance.

Dr. Runco 20-04-2015, 09:41

Jason what is a “severely” torn plantar plate in your opinion. Tears come in many varieties
Grade 1 – rarely requires surgery if treated appropriately
Grade 2 – Partial tear. May require surgery but if treated early in the process it demonstrates the ability to heal well. I know this because I suffered a partial rupture and healed perfectly in 4 months. I have run multiple 50 mile events since then and my foot is fine. I have been successful in helping hundreds of others do the same
Grade 3 – full tear or rupture. Will usually require surgery and I almost always advise it in this instance.

jason 22-04-2015, 08:46

I consider a Grade 3 tear as severely torn but as far I am concerned I would go for surgery even if there is a Grade 2 tear as you better be safe than sorry. Yes your rupture healed perfectly in 4 months, however 4 months is quite a lot of waiting time and that might risk further injury. What if you were to fall over or slip somewhere? What if you bumped your leg somewhere? To avoid aggravating the tear, I would go for surgery if there is a partial tear that would take a long time to heal naturally.

Dr. Runco 22-04-2015, 08:59

although what you are saying may have some merit it is not based on current healing models. Surgery always comes with implied risks the worst of which is infection. The recovery time from plantar plate surgery cna be 3-6 months and the outtcome is not guaranteed. When one wants to avoid surgery and the asociated risks they can
1. protect the area by wearig a sport walking boot
2. tape the toe into proper alignment to ensure the injured tissue is approximeted and will graft itself
3. do therpaies to increase blood flow into the plantar plate ligament to enhance nutrients and oxygenation of the tissue
4. gradually stress the injured area as it heals. Ligament is connective tissue and will respond positively and strengthen in response to proper stress
5. Return to normal activity gradually as the injury and pain lessen.
6. get custom orthotics with metatarsal pads to support the transvers/metatarsal arch and plantar plate ligaments
7. Consider modifying whatever the offending activity was that may have been responnsible for their injury
I have treated hindreds of runners and non-runners with various degrees of plantar plate injury…..many who failed surgery as well. While I appreciate your feedback your concerns are unfounded and not based on current medical models for tretment of this injury.

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