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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

Cristina 07-02-2014, 17:33

Hi Dr. Runco,

I’m hoping you might be able to shed some light on my situation. Apologies in advance for the long backstory but I just wanted to make sure I was able to give justice to the journey me and my feet have been on thus far! I am, like most in this thread, a runner, or at least I used to be. About a year ago (Dec 2012) I started feeling pain under my my second toe joint on my left foot after x-rays and MRIs galore between orthopedic surgeons, rheumatologists and podiatrists, they diagnosed me with synovitis, saying that because my second toe was longer than the first I had over taxed my second toe joint. Furthermore, it was explained to me that with the way I was walking my big toe wasn’t bearing hardly any load, leaving the smaller joints to bear the burden. I used metatarsal pads and had a cortisone injection at the site, to no avail, custom half length orthodics made, then full length orthotics made and it looked like all might be healed, this was around April. I had another MRI and it looked like the inflammation had disappeared. They gave me the green light to start running again (as I had stopped entirely since about Jan/Feb of 2013 – forcing me to pull out of the Boston Marathon), which I did slowly but surely, working my way up to only about a three mile run once maybe twice a week at around 8/3:30/9 min miles flat. Then around end of July (so about 2-3 months later) my right foot (so the other foot) all of a sudden was in excruciating pain. In the same-ish spot, under the second toe joint. I was on vacation at the time so as soon as I came back I went to the podiatrist who made amends to my orthotics and sent me to the rheumatologist who put me in an aircast boot. I was in the boot for 6-8 weeks. At around week four when the amended orthotic was ready I put that in the boot as well. When I came out of the boot my foot was still very swollen and I still had a lot of pain. I then exclusively wore brooks adrenaline sneakers with my orthotics for 3-4 months. Concurrently the doctors ran all sorts of blood tests and the only thing that came back was some sort of “inflammation” in my blood, a sero negative result. However I was negative for all other tests, rheumatoid arthritis, lupus etc. I started anti inflammatories (naproxeon etc) and then arthritis meds (sulfazalosine) and steadily increased doses for 6 months. As I live abroad in london all of this took place in private clinics over there. I finally decided to come back home to the states, ny/nj area and go to the Hospital for Special Surgery in Manhattan. There I saw another orthopedic surgeon who sent me for a more specific/better MRI (apologies for my ignorance) because it was his opinion that it was my plantar plate, which he couldn’t see in my previous 3 MRIs. Indeed when the results came back there was a depression of my plantar plate (although he didn’t talk about which level of sprain/tear as I see you’ve mentioned in your previous posts). He sent me to someone who made me a new ‘more aggressive’ pair of orthotics and suggested I exclusively wear shoes with a rocker bottom sole, specifically Scott e-ride sneakers, which I have been. She also suggested I not walk barefoot at all and suggested I get a pair of crocs and fit flops for when I can’t be in my sneakers which I have. I’ve been following this course of treatment only for about 1.5 weeks now and am set to go back to the doctors in 3 to gage progress etc. so far it does feel a bit better when i’m walking around but it’s still painful especially when I probe the area. In the meantime I’ve also tried acupuncture and epson salt soaks to attempt to relieve the pain.

All that to say I guess I’m just a bit desperate and don’t want to go through this for another year waiting to see if it will work before soliciting other opinions. I’ve had to take a sabbatical from work and am just tried of sitting around unable to be active. I’m completely at my whits end here!?! I’m dying to be able to do something, anything! And it would just break my heart if I could never run again. I’m thinking about trying to squeeze in a weekend trip to California while I’m home, do you take last minute patients? Do you think it would be worth a consult? Please help!?!

Thanks in advance for any advice you could offer. I would be incredibly grateful for any suggestions!

Dr. Runco 07-02-2014, 21:58

Hi Cristina,
It would definitely be worth your while to come see me. I Have many ways of dealing with this issue to make it better. Cristina please email me at my personal email drrunco@sdri.net and give me your phone number and the date(s) when you are coming to California and I will have someone from my office call and schedule you. I look forward to meeting you….and helping….fyi I am from NYC too :)

deb pezzuti 24-02-2014, 13:50

I am scheduled for surgery tomorrow and I am terrified for plantar plate tear. No one has told me what grade it is and the last dr didn’t BOTHER looking at the MRI ..I have done conservative treatment for 2 years.

Dr. Runco 24-02-2014, 14:03

I am being as honest as I can be here……if you are scheduled for surgery tomorrow and emailing an anonymous doctor (me) the day before what do you hope to gain or want me to say? Why would you allow someone to knock you out, lay you on a gurney and cut open your foot……to do what kind of surgery exactly? If you are not sure and do not have confidence then maybe you should call of the operation Deb.

Mel 12-03-2014, 09:46

I too have a plantar plate tear. Firstly diagnosed as bursitis for 4 months until an ultrasound revealed the injury and unfortunately arthritis. My orthopaedic surgeon is reluctant to operate and I have been referred to a Podiatrist to firstly try the conservative method which sounds like the method you would have chosen too.

I have been wearing the orthotics for the past 3 weeks, the process being very uncomfortable however I am under the opinion this process is no pain no gain.

Id appreciate your feedback and will keep every one here posted on my very slow mending process. Im gathering patience is advised

Dr. Runco 12-03-2014, 13:09

Mel I highly encourage you to use me as your patient advocate for this injury. Treating plantar plate tears is tricky and not as straight forward as may seem. For example; the degree of tear dictates how aggressive the course of action should be. Liken a plantar plate tear to a cut on your skin….they are both tears. If you have ever had a small cut on your skin you know it hurt, it bled and it healed without surgery or even stitches……skin is connective tissue exactly in the same way a ligament is connective tissue it just has more blood supply so it can heal a little easier and faster. Now imagine a serious gash on someone’s skin, a jagged deep cut that requires serious stitches and leaves a nasty scar. Both of these scenarios illustrate tears to your skin but each circumstance requires totally different interventions and end up with completely different outcomes. The same is true of your plantar plate ligament. It is vital to know how severe or the degree that the ligament is torn.
When instituting a treatment regimen it is important to consider the severity of the tear and then to protect that tear form further injury. In some instances a very stiff walking boot is required while in others a rocker bottom shoe may suffice and yet in others an orthotic with a properly placed metatarsal support may suffice…..depending on the severity of the tear. Let’s look at each condition briefly;
1. Walking boots – are not all created equal. You can have a very comfortable walking boot (I’ve personally tried 20…some are horrible) or you can have a useless uncomfortable boot that actually aggravates your foot………UNDER NO CICUMSTANCE SHOULD YOU DO ANYTHING TO AGGRAVATE YOUR FOOT!
2. Rocker bottom shoe – can prevent you from flexing your plantar plate and walk without pain…if the tear is not so severe. Allows for more function when compared to a boot. Boots also tend to make you feel like one leg is longer than another and can cause you back issues.
3. Orthotic with metatarsal support – If the orthotic is uncomfortable and the metatarsal pad is pushing up on the injury IT IS MAKING IT WORSE! I do not care what the dopey doctor tells you….pain is not your friend and should be avoided at all costs. Pain is your body’s way of telling you there is a problem. Listen to your body….it knows best.
4. Metatarsal pads/supports – if not placed properly will aggravate your condition. Metatarsal pads can be adjusted to a persons foot size, body weight and shoe type. If you place a thick metatarsal pad that does not give under a 100 lb women I can predict the outcome. The same metatarsal pad under a 200 lb. man will probably work fine….same metatarsal pad but completely different outcomes. Most doctors use the same hard orthotics and same unforgiving metatarsal pads that aggravate patients plantar plate….do not let them do this to you!
I have seen so many patients follow the well intentioned but completely misguided advice of doctors incompetent in this area only to end up with pain for years. I can help you end this pain quickly. Modestly aside I am the authority on this injury. Not only have I treated it and learned from my experience over the last 14 years but I actually had it 2 years ago…I know exactly what it feels like and how to get it to heal. There are simple measures that can be implemented to allow this injury to heal but it has to be protected and pain free as possible.
Please call my office after 9am today at 858-268-8525 and Krista will schedule you for a ½ hour phone appointment ($125) where I can go over this injury in detail with you, make sure you as educated as possible about it and have as much information going forward so that you can make the best possible decisions regarding your own path to getting better. After our phone consultation you will fell 100% more confident in the direction you decide to take and manage your condition back to health.

Adrian 13-03-2014, 05:26

Hi – First of all, thanks so much for such a valuable website. I have been seeing a local doctor about a severe pain experienced in the ball of my right foot, in line with the 3rd toe. I had been doing a lot of jogging and hiking, and also training with a heavy pack and boots. Never had a problem with any of that – but walking back from the supermarket one day in a thin-soled pair of shoes, I suddenly experienced a shooting pain that was just too painful to walk on. I stopped running and let it rest but the pain didn’t really get any better. I eventually went to a doctor for an X-ray because I was concerned I had a stress fracture. The x-ray didn’t show anything unusual but the doctor said I had a high-arch and that I’d got tendonitis. He put me on a course of ultrasound and physio, but actually it didn’t make any difference. In the end I bought an expensive arch-support insole from a sports shop, and then started modifying it by adding padding under the metatarsal heads and additional arch support to spread my weight over a wider area. This seems to have made a difference, and I can now hike and jog pain free.

My question is – does this sound like a planar plate tear to you? And if so, as long as I remain pain-free, would you say my remedial strategy is good?

Dr. Runco 13-03-2014, 10:46

Hi Adrian,
Thank you for the compliment, I put a lot of effort into my website. From your email description I am going to give you my best estimation based on the probabilities. Most likely you did not have a plantar plate tear but rather bone marrow edema (bruised bone inside the medullary cavity). Had you suffered a plantar plate tear you most likely would have had to immobilize your foot as any bending of the ligament will typically cause pain and delay healing.
There are 3 basic Arch types. High (Pes Cavus), Medium (Pes Rectus) and low (Pes Planus). High arched individuals do not spread pressure throughout the entire bottom of their foot in the way flat footed people do. Pressure is typically directed through the ball of the foot and heel. Combine this with running and you have high, repetitive impact on the ball of the foot and increased impact forces that can result in bone trauma. X-rays would not show bone edema nor would it have shown a stress fracture or tendonitis for that matter. I do not know what the doctor based his/her diagnosis on but in my experience most doctors never even touch the area and will somehow declare it to be tendonitis…..if questioned they usually can not even name the tendon they are pronouncing to be “itis”.
You then got expensive arch supports from a sports shop and started modifying them. Congratulations you are now a custom orthotic maker (if you would like to interview for a job please give me a call…..I could use another custom orthotic maker)! By customizing your arch support molds you did an extremely intelligent thing that makes a world of sense…..you added metatarsal pads and additional support to “spread weight over a wider area”. This worked because it redistributed forces throughout your entire foot and not just on the ball of your foot and 3rd metatarsal. You must be an engineer…….or at least you think like one 
If you are pain free than there is no problem and your strategy was a great success. Pain is your body’s way of letting you know there is a problem. We are all hard wired this way so we can protect ourselves from further injury. If you place your hand over a hot open flame it hurts so that you have a warning sign that damage will occur if you do not move your hand…..so you move it. If you move your hand further away you do not feel the heat thus no damage. Continue running and monitor the area for any worsening of the condition…..it should be fine from your account. If you have any more questions feel free to email me at DrRunco@sdri.net.

Michele 30-03-2014, 11:54

Thank you for your website. When I read your planter plate tear I knew you knew exactly what I am experiencing. I think you are the only website out there that is an expert on this and because it’s on your homepage it must be very important. I was just diagnosed after two years of “neuroma or hammertoe” types of treatment with cortisone that my MRI revealed a “tear” with the 2nd toe or on your site as grade 2 type sprain. I am wondering what makes you decide surgery or boot? My Podiatrist offered both and since they both involve the boot I thought “maybe surgery will fix this from ever tearing again”. My previous experience with turning down surgery on my shoulder is that after so many cortisone shots it broke down from a partial tear to a full tear. I was in surgery in 2 weeks from that MRI. I don’t want my foot to end up the same emergency situation and total pain because I turned down surgery. What is your patients experience with the “stiffness” in the joint after surgery due to scarring from the plate repair? And why would you shy away from it? What are the risks?

Dr. Runco 30-03-2014, 16:29

1. Do the boot first….you can always have surgery
2. As far as I am concerned the word podiatrist typically means “Incompetent” find an orthopedic foot surgeon that specializes in foot/plantar plate
3. Your Podiatrist has already mis-diagnosed you once and damaged you with cortisone. Don’t let them inject you again. Cortisone is a catabolic hormone, meaning it is destructive to inflammatory enzymes….and your tissue in this case your plantar plate. I hope your realize that and understand what actually occurred to your shoulder. You had damage and they shot it with cortisone allowing you to not only make it worse but the cortisone itself helped destroy your tendon and set you up for surgery. Nice racket those doc’s have eh?
4. There are many, many other things besides a boot you can do to avoid surgery Michele. I would like to help you and become your patient advocate. I have helped hundreds of people around the USAA and Europe by functioning in this regard. If you would like my help with this please email me at DrRunco@sdri.net and we can set up a phone consultation where I will go over your injury with you, explain how it happened, tell you how to manage it without surgery so that it also heals 100% and make you much more comfortable with knowledge going forward.

Liz Cannon 01-04-2014, 14:35

So glad I found your site, maybe you have that magic bullet I’m looking for! I’ve had the pain you explain under second metatarsal head, foot surgeon/orthopedist said he thinks I”ve got a plantar plate tear, but no mri. Like you, he said surgery should be last resort (I have hammertoe and bunion on both feet.) I work in a physical therapy office, have access to ultrasound and stim with heat/cold any time. Doctor gave me met pads and toe spacer socks. Did I read that you don’t want the foot to be flexed? Any exercise/movement suggestions? Heat or cold? I had a morton’s neuroma removed from the other foot a year ago, and surgery was replaced with extreme bursitis and possibly a stump neuroma. Both feet are in extreme pain, of course now my whole body is in pain due to compensation and gait change. I can’t run at all, barely walking. Help!!!

Dr. Runco 01-04-2014, 14:42

i would be happy to help you Liz. I can set up a phone consultation for you if you like. At that time we can review any and all options you have that will help you avoid surgery. I am an expert on this condition and while I would prefer to physically examine you and speak to you in person i can be effective over the phone and help guide you through this terrible condition. If this is something you would like please contact me at my personal email DrRunco@sdri.net
Not only do I treat and fix this condition regularly but I had a grade 2 tear myself that I fixed without surgery. In fact my most recent MRI 3 years post injury does not even show any scar tissue and i’m running a 50 Km Trail Race on Saturday…shout out Oriflamme 50K!I am also running the PCT 50 Mile Trail Endurance run on May 10th….no foot issues whatsoever. I look forward to helping you Liz

Liz Keogh 13-04-2014, 04:07

Hi there,
I too have had a plantar plate tear. After trying different things for 6 months, pads, taping etc I had surgery. I also had a bunion ( hallux valgus ). The surgery was to repair the tear and fix the bunion. I had this surgery in July 13. It was called weil something. Prior to this injury I was a recreational runner- ran up to 6 or 7 Kms slowly per week with a training group. After surgery I did nothing for 5 to 6 months and then have returned to my group but only walking and upper body strength activities. The problem I have is continuous swelling under my foot. If I stand all day or am on my foot for long periods I feel like a painful lump is under my foot. I have iced it , had massage twice a week initially to reduce the swelling and now every time it seems to inflame. My surgeon says the surgery was successful but my recovery seems to be long. After severa weeks back at training I ran for about one kilometer and end up with a sore foot again. In fact my foot always seems to be a little bit painful. I wear shoes that are orthotically correct. Should I be doing different things? Exercises? My physio says I havea chronic condition and when I push it it becomes acute and sweets again. My family have a history of bad circulation.
Any thoughts ? Any ideas that may help me recover?

Dr. Runco 13-04-2014, 13:32

You need to try specific running shoes that help many with your problem. They don’t fix it but often help. It also seems that your surgeons idea of successful and your own are not the same. Your physio’s opinion is that the surgery was not successful and you are left with a chronic condition. You need to try custom orthotics with metatarsal pads, HOka Running shoes and PRP injection into the plantar plate.

Chris Phillips 22-04-2014, 17:54

I have been to 3 different doctors at different times after I felt a ton of pain in the ball of my foot during my last run 2 years ago. The first Dr told me I had pre-dislocation syndrome and prescribed a steroid pack and an anti inflammatory. That medicine took me from a pain level of 9 to a 2 in 3 days.

I waited for several months before running again. Walking I had very little pain, but after my runs (or during sometimes) the pain would come back. Trying to avoid surgery since I’ve already had 2 major back surgeries, I kept hoping things would heal on their own. That didn’t happen, so I went to see a 2nd Dr. He told me that I had hammer toe, recommended surgery and had me tape my big and 2nd toes together for maybe 2 – 3 weeks, along with inserting a metatarsal pad on my expensive running store insoles. This helped quite a bit with walking, but still every time it went back to running the pain, although not nearly as bad, would come back.

Finally, 2 years after this injury I finally decided enough was enough and went to a 3rd Dr to request surgery. This Dr diagnosed the injury as a plantar plate tear. So, 3 Dr’s and 3 different diagnosis.

I am actually scheduled for Surgery in 2 days. I called the hospital to find out the facilities charges and was BLOWN away. Procedure is about 1 hour according to my Dr, along with a 2 hour recovery.

Surgeons fee is about $3,000, anesthesiologist is $750 for 1 hour, and the facilities bill is $15,000. Those are the rates that are contracted with my insurance company – United Health Care.

I couldn’t even BEGIN to imagine anyone charging $15k for a 3 hour hospital visit. For that price, I’d want the entire hospital staff in my room during the entire procedure and recovery. Really? $15k for a 3 hour visit? By the way, this is in Lincoln, NE.

I called the Dr’s office to ask if the Dr does this procedure somewhere else and they told me of another place. I called them and the contracted rate for the same procedure was 1/5 of the hospital – $3,300.

I’m writing this in case this might help someone out. Make sure you know what the facilities charges are because they obviously vary drastically in cost.

For $15,000, I’d choose to just walk with no pain and know I couldn’t run. For $3,300, I’m getting it fixed.

What a bunch of crap our medical system is. I hope i never need to go to the hospital. Freaking ridiculous.

Dr. Runco 22-04-2014, 22:04

I hope the surgery fixes your torn plantar plate Chris. Sorry you had to learn the truth about our medical system the hard way. Now you know. To be clear Doctor’s 1 and 2 were…………incompetent. “Pre-dislocation syndrome” is another way of saying you have damaged ligaments….er….maybe a damaged plantar plate doc #1?
Doctor number 2…another genius told you that it was a hammer toe. A hammer toe happen BECAUSE of a plantar plate…google it doc! The 3rd doctor diagnosed accurately what the first 2 actually already diagnosed….they just did not know it!
We are stoked you found a facility that charges way less to host the surgery. Good luck with your foot and your recovery Chris!

Gerard McDermott 27-04-2014, 11:27

Hi, my name is Gerard and I live in Sydney, Australia. I recently completed an Ironman Triathlon but was suffering with substantial forefoot pain for 4 months leading up to the event. I saw several medical people and varying diagnosis. I was given 2 cortisone injections which didn’t assist me very much. It is now 5 weeks since the Ironman, which I was able to complete under my goal time but the last 20km of the run really hurt my foot. I have recently seen a foot surgeon (specialist) who believes I have a planter plate tear. I am now completely resting from running for the first time and I am having orthotics made as well. I was told that I could continue to swim and ride my bike but that it would take several months to heal. If after 6 months it hasnt healed then surgery is the recommended action. Clearly, given that I live in Australia there is not much you can do for me. I really wish you were local as you really seem to know all about this particular injury. I was hoping you could answer one question for me. That is how important do you think it is that I wear a boot during this healing time as my specialist did not mention that. Also, do you agree that it is OK to swim and ride during the healing time. Many thanks !!

Dr. Runco 27-04-2014, 15:50

Sorry about the foot Gerard. The purpose of the boot is to limit any flexion of the toe/ligament thus giving it the best chance to heal…..any aggravation of the injury can worsen it. SO yes, I think a boot necessary for at least the first 6-12 weeks. Swimming and biking (no flip turns) are fine.
The OSSUR low cut walking boot is my preferred boot

Mike Shipley 03-06-2014, 17:46

I’m looking for some advice. I tore my plantar plate two years ago. We finally found in an MRI last summer after months of rehab no working. I wore a flat walking shoe and taped my toe down(second metatarsal) for three months. It was not a complete tear so it was a grade 1 or 2. I had no toe or joint deformity. My toes have the natural raised look in general. So the boot was removed in September and I have been in rehab ever since. We’ve been doing the rehab once a week which involves a deep tissue massage if you will to stretch my calf and hip. So I get the rolling buzzing around my foot and has slowly been going away. We do balancing and footwork excerscizes. So it’s been 9 months and not “healed”. I’ve read on here it can take up to a year. To my question is can it take a year or longer to get the tendon back to normal and the atrophy out of my foot from the boot? I’m on the beach this week for the first time since before the boot and it has made the second metatarsal ver sore. Thanks for any advice you can give. It can get depressing taking all this time.

Thanks

Mike

Dr. Runco 03-06-2014, 18:00

I can advise and help you with this condition but it will be necessary for you to schedule either an office visit or a phone consultation. If you would please call my office at 858-268-8525 we can schedule whichever one you prefer. It does not sound like you are doing what is necessary to fix it currently.

Katie Shea 22-08-2014, 12:31

Hi,

My 2nd toe is progressively moving on top of my big toe. I’ve seen a podiatrist who prescribed 10 weeks of an anti-inflammatory. I have 3 young children and don’t want to lose any mobility by just letting the toe continue to drift. Less importantly, the podiatrist showed me a picture of orthopedic shoes to order. I really would rather just get my foot back to normal, if possible. Is it possible, and how do I make that happen? Thank you

Dr. Runco 22-08-2014, 15:00

Hi Katie,
Sorry to hear about your foot. The answer is yes you can fix your foot. You have a torn plantar plate/lateral collateral ligament tear in your toe where your second metatarsal meets your toe. Ligaments help hold joints together which is why your second toe is deviating. This condition is sometimes referred to as pre-dislocation syndrome because your toe is moving out of its normal range.
The podiatrist you are seeing is either lazy or ignorant. Antiinflammatories are not going to help or fix this and neither is an orthopedic shoe. I highly encourage you to call my office today after 10am and ask Krista to schedule you for a phone consultation or office appointment with me. You need help from someone who knows how to correct this condition and I can advise you as I am an expert in this condition.

Laure Simms 29-09-2014, 17:05

Hi Dr Runco
Long stroy, I started having pain in the ball of my foot behind my second toe last Sept. I was three weeks out from a 10 mile race so I went to a Ortho foot specialist that diagnosed a Mortons Neuroma. Cortisone injection felt better and ran my race. The pain was more aggravating than anything. Between Oct 2013 and Feb 2014 I ran three 10mile races and three half marathons. The pain has come back and just won’t go away. I have numbness in my second toe at times as well. I have had this foot injected three times and still no permanent fix. Was told by a different doctor that I had Metarsal Capsulitis. After reading through your website it sound more like a plantar plate problem. Just wanting an opinon to request an MRI or what would be the best course

Dr. Runco 29-09-2014, 17:45

Hi Laure,
You could have;
1. Mortons Neuroma ( you have numbness into your toes)
2. Plantar Plate Sprain/Tear (most likely diagnosis. This is a severe sprain common in runners and can cause burning or numbness into toes as well)
3. Capsulitis (might be secondary to Plantar plate tear)
4. Metatarsalgia (it is possible you have bone marrow edema in your metatarsals)
5. Stress Fracture (very possible to be a stress fracture AND a Plantar Plate Sprain)

I am an expert in the diagnosis and treatment of these injuries Laure. I have seen hundreds if not thousands of runners misdiagnosed, told to get shoes or inserts by incompetent doctors, useless and needless surgeries for neuromas when in fact they have a plantar plate sprain/tear that eventually ruptures. If you feel the pain is getting worse that is a clear indicator that the damage to the bone, joint or ligament is worsening. I have a personal history with this injury Laure. I was suffering from metatarsal pain when the pain went from bad to worse instantly. An MRI revealed a torn plantar plate ligament. I narrowly avoided surgery. Do you get burning into your toes? If you look down at your foot does the toe look like it is deviating away from the other toes towards you big toe? (you can send a picture) Do you have any other foot condition like bunions? I strongly urge you to follow the instructions below Laure. After running well over 15 marathons and 10 ultramarathons in addition to treating injured runners over the last 14 years I have learned many “tricks” to help alleviate these types of conditions. I look forward to helping you.
If you not live in the San Diego area, you can schedule a phone consultation with me. The consultation is $125 and by calling my office at 858-268-8525 after 12 noon Pacific Time Monday, Krista can schedule a 30 minute phone appointment. These are very successful because prior to the phone consult you,

1. Provide me with a detailed history regarding when and how the pain started.

2. Any and all doctors, therapist etc that you have seen and what exactly they tried to do to help you

3. Anything you did on your own that may have helped or hurt

4. A list of any special tests including X-rays, MRI’s, blood tests etc

5. Any information you have I may need to know.

6. Three Links to either sports chiropractic offices or physical therapy offices YOU FEEL might be able to help you.

After reviewing you information we will have our phone consult. During this time I will ask you very specific questions as well as get you to perform on yourself, with my direction, Orthopedic testing to help me diagnose your condition. I often find runners to be misdiagnosed or under diagnosed. After narrowing it down I will provide you with a written, detailed report with all of my recommendations. I will also research the 3 therapy/chiropractic offices you provided me links for. The two of us will then pick one and I will either email or fax them the protocol that they should use to fix you. My success rate is very high here in San Diego; I personally treat and fix these conditions on a regular basis. I am able to help runners all over the country through this simple process.

Callie 03-10-2014, 14:28

Dr Runco,
Are there any homeopathic aids that will help with a severe plantar plate tear? We are using the boot, and pads and while this has reduced some of the ball of the foot pain it has increased pain in the big toe. There are 3 stress fractures in the plantar plate (revealed by MRI) and 5 doctors opinions all have led to the this boot, different pads, and time to heal. So far it has been 7 weeks. However the pain is sometimes unbearable and the situation seems to be worsening.
Would things like icy hot naturals help with pain? Or Lemongrass oil massage into the area to help aid healing and pain? We do epsom salt baths. Can you tell me what ultrasound therapy is? And also could you shed any light on the different types of boots available? I see you’ve tried 20! We have only used one and it doesn’t eliminate the pain, but the doctor has not recommended any other types even though he knows that there is still alot of pain. Thank you in advance for your help. Your website is truly amazing -offers hope!

Dr. Runco 03-10-2014, 20:54

Callie would you prefer to set up a phone consultation with me? I think you would benefit greatly from it. If so call my office at 858-268-8525 and Krista can schedule it for you.
There are a few things you say in your email that don’t add up and concern me. I believe your doctors are leading you down the wrong path.

Callie 04-10-2014, 00:41

Dr Runco,
It is something Id consider, but Im not sure if my insurance would cover that sort of medical consultation.
I guess my main questions for you were just your opinions on pain reduction during the healing time. With adverse reactions to many anti inflammatory meds (hives) I am looking into homeopathic options. I saw you mention ultrasound therapy so I was just wanting more info on how that works.
I feel like were on the right path but may need to try different boots, pads. Im not sure what you mean when you say you believe we are on the wrong path? Diagnosis or treatment?
Thanks again!

Victoria Coleman 11-10-2014, 06:02

HI Dr. Runco
I like all other posts need to tell you finding this site has given some hope and insight into my PPL tear. I am a 5 year marathoner, a fairly serious runner. recently after some rock climbing and jumping in very poorly padded barefoot style shoes while holidaying in Arizona i developed fairly severe pain under my 2nd metatarsal area, more specifically acute point tenderness at the 2nd metatarsal phalangeal joint. In all fairness i had had some mild pain at this spot even prior to the hiking/running in AZ. i am a forefoot runner and have run injury free for years. I had swelling appear both on the plantar and dorsal aspect of my foot. like a dumb runner and doc (never doctor thyself) i came home and thought i would test this foot by a strong speed work out…BAD idea. i ended up very swollen and with dorsal bruising that become apparent the next morning. DUMB GIRL. after a month or trying ice baths, laser and what i called rest ( really not much rest at all) i had a bone scan and US. Clear Bone scan so no fx, but did show swelling of the bursa. no surprise. I then saw a very good podiatrist that deals with athletes. It took him 30 seconds to say it was more serious than I thought, and it was a tear (possibly full 3rd degree) of the plantar plate. we tried one week of taping but i am on my feet a lot, still doing elliptical, and biking…and foot was swelling and stabbing pain at the site. limping… that is a given if i exercise or by end of any normal day. I now had to succumb to a boot cast. I am waiting an MRI. I feel very hopeless and i now feel a bit of this happening on the right foot! nuts. not as bad but it scares me.
just wondering if i can keep doing my wts/elliptical/bike routine, should i water run, how long do i need the boot cast. if there is more you can share with me to get this to heal i would book in via a phone consult. i have an entry into Boston to run it again but feel very discouraged right now. i have been four days in a boot cast and HATE it but will do IF someone tells me it will truly help this!
up late researching in Canada hoping for answers.
thank you in advance!
Victoria

Dr. Runco 12-10-2014, 13:50

Hi Victoria,
First let me sat that I am sorry to hear about your injury. Below are the possibilities not necessarily listed in the order of likelihood but do cause pain in the area you are describing.
1. Mortons Neuroma – Do you have “burning” into your toes?
2. Plantar Plate Sprain/Tear (most likely diagnosis.) – This is a severe sprain common in runners. When you look down at your feet is your second toe deviating towards your big toe?
3. Capsulitis (might be secondary to Plantar plate tear) – The joint capsule is part of the plantar plate, medial collateral and lateral collateral ligament of the MTP joints for all practical purposes.
4. Metatarsalgia (it is possible you have bone marrow edema in your metatarsals)- Unlikely but possible. The MRI will show it…assuming it is a quality MRI
5. Stress Fracture (unlikely considering the CT scan for it to be a stress fracture AND a Plantar Plate Sprain)

I am an expert in the diagnosis and treatment of these injuries Victoria. I have seen hundreds if not thousands of runners misdiagnosed, told to get shoes or inserts by doctors that mismanage their condition because they do not truly understand the physiology of connective tissue healing and what it takes to heal a plantar plate ligament AND avoid the knife at the same time.. If you feel the pain is getting worse that is a clear indicator that the damage to the bone, joint or ligament is worsening. If any of the exercising is causing increased pain you are only damaging the ligament more. It now sounds like you are compensating and causing a similar issue on your other foot. I have a personal history with this injury Victoria. I was suffering from metatarsal pain when the pain went from bad to worse instantly. An MRI revealed a torn plantar plate ligament. I narrowly avoided surgery. Do you get burning into your toes? If you look down at your foot does the toe look like it is deviating away from the other toes towards you big toe? (you can send a picture) Do you have any other foot condition like bunions? I strongly urge you to follow the instructions below Victoria. After running well over 15 marathons and 10 ultramarathons in addition to treating injured runners over the last 15 years I have learned many, many methods to help alleviate these types of conditions without the use of surgery. I look forward to helping you.
Since you do not live in the San Diego area, you can schedule a phone consultation with me. The consultation is $125 and by calling my office at 858-268-8525 after 12 noon Pacific Time Monday, Krista can schedule a 30 minute phone appointment. These are very successful because prior to the phone consult you,

1. Provide me with a detailed history regarding when and how the pain started.

2. Any and all doctors, therapist etc that you have seen and what exactly they tried to do to help you

3. Anything you did on your own that may have helped or hurt

4. A list of any special tests including X-rays, MRI’s, blood tests etc

5. Any information you have I may need to know.

6. Three Links to either sports chiropractic offices or physical therapy offices YOU FEEL are competent.

After reviewing you information we will have our phone consult. During this time I will ask you very specific questions as well as get you to perform on yourself, with my direction, Orthopedic testing to help me diagnose your condition. I often find runners to be misdiagnosed or under diagnosed. After narrowing it down I will provide you with a written, detailed report with all of my recommendations. I will also research the 3 therapy/chiropractic offices you provided me links for. The two of us will then pick one and I will either email or fax them the protocol that they should use to fix you. My success rate is very high here in San Diego; I personally treat and fix these conditions on a regular basis. I am able to help runners all over the country through this simple process.

Kimn Chartier, R.Ph 20-11-2014, 15:18

Dear Dr. Runco..

Right foot is extremely swollen, 2nd toe just crazy enlarged, can hardly walk. Started running about a year ago.. Dr’s said this is what caused it all. MRI states that I MAY have a partial thickness tendon tear near the plantar plate and a 3mm cyst. One DPM wants Orthotics (sp?) and another wants to repair the tendon. I am so over this all that I just believe surgery is my best option. The top of my foot is swollen as well as the bottom, I cannot bend my second toe. My question is with a partial tendon tear would surgery be the best option and why would not the first DPM who ordered the MRI even address that tear? I am sincerely tired of limping in pain and taking Medrol Dosepaks. Sincerely a frustrated RPH.

Dr. Runco 02-12-2014, 15:20

How can I say this……it is possible that the 1st DPM thinks or hopes that by taking pressure off the tear your body will be able to repair itself……and if it does not work then he/she can always operate. This is common practice in that it will appear they are trying to help you avoid surgery but it is possible they are sure it will not work and will end up having surgery anyway so they make money in two ways. I view this as unethical or ignorant. I am also skeptical of your diagnosis. Are you sure it is the tendon and not the plantar plate ligament itself. Can you email me a copy of the MRI report. Snap a picture and email to drrunco@sdri.net
There are many viable treatment options other than surgery but how you manage this condition starting now will dictate how well it will heal.

Tim 02-12-2014, 22:54

Hi Doc,

I developed pain in the ball of my left foot at the end of July while and stopped running altogether. I don’t recall having much pain prior to the day I stopped running except for some tenderness on the top of my feet but not enough to cause me to stop running. At some point after I stopped running, I noticed that might right foot had some, but less, discomfort in the same place. The condition did not get better over three months so in October I saw a podiatrist who diagnosed a plantar plate sprain. He recently sent me for an MRI and the result is that in my left foot I have a full thickness tear of the plantar plate of the second metatarsal and a partial tear of the plantar plate of the third metatarsal. On my right foot, I have a full thickness tear of the second metatarsal. I am surprised by the severity of the diagnosed injuries because I did not experience any swelling and my toes all seem normal, do not appear to be deviating, and touch the ground. My podiatrist thinks the condition developed over time and has recommended surgery on BOTH feet (w/ osteotomy because my second toes are long). I told him that I won’t do that until I have completely exhausted my conservative treatment options. I don’t have any interest in toe immobility or deformity, nerve damage, stiffness, or any of the other problems reported by those with surgery. Podiatrist has me taping both second toes with Budin splints, in orthotics that seem to shift my weight to my heels but no metatarsal pad or cusion, anti-inflammatories, and icing regularly. Too early to tell if there is improvement. I just want to get back to normal and run agian some day. I’m willing to put in the work to get there but need help with a plan and a reality check that I am not just being stubborn and can get there without surgery. I feel like I am in the same category as Victoria above except I have the MRIs to prove the bad news (although I understand that even MRIs are not so good at diagnosing PPTs). Help!

Tim

Dr. Runco 03-12-2014, 20:53

OK Tim. There are definitely ways to attempt to fix this without surgery. Please call my office at 858-268-8525 and tell them you want a phone consult. At that time I will outline a strategic and proven treatment plan for you. After that you will be confident going forward. The cost of the phone consult is $125. Please fill out the new patient electronic forms on my website at least 3 days prior to our consult

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