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. 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. 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.
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 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.
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.
So what is a Plantar Plate Sprain?
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 Sprained/Torn Plantar Plate Ligament?
Depending on the severity of the tear depends on the course of treatment that will be effective. 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.
Will I Need Surgery to Correct My Torn Plantar Plate?
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.
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.