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Running Injuries What is a plantar plate tear? How do I know if I have one? The metatarsal pads the doctor gave me hurt worse than the injury! I tried PRP it did not work! My doctor is recommending a cast, do I need that?

What is a plantar plate tear? How do I know if I have one? The metatarsal pads the doctor gave me hurt worse than the injury! I tried PRP it did not work! My doctor is recommending a cast, do I need that?

What is a plantar plate tear?  How do I know if I have one?  The metatarsal pads the doctor gave me hurt worse than the injury!  I tried PRP it did not work!  My doctor is recommending a cast, do I need that?

What is a plantar plate tear?  plantar plate tear

A plantar plate is a ligament.  Ligaments connect bone to bone at the joint and provide structural stability for the joint.  If you tear a ligament not only is there pain but you lose structural stability which can lead to severe problems in the future.  Often when you tear a ligament, in this case the plantar plate, you will see joint deformity.  When the plantar plate tears you will often see the toe involved deviating opposite the direction of the injury, in most cases this would cause the toe to deviate medially or towards your big toe.

How do I know if I have a plantar plate tear?

2nd toe is deviating towards big toe due to ligament tear

2nd toe is deviating towards big toe due to ligament tear

You will begin to have pain in the ball of your foot that approximates your 2-4th toes.  The pain will usually be worse when barefoot and during activities like running and jumping.  At first the pain is relieved by rest but soon the pain will continue to worsen and be painful all of the time, even during non-weight bearing activities.  Many describe the sensation of “walking on a rock” or walking on a pebble or marble”.  I have even heard runners say they felt like their sock was bunched up beneath the area.  In later stages of the injury you may notice your toe is deformed, meaning that when you are standing and look down at your feet you notice the injured toe is deviating in a way that it never used to.

I tried metatarsal pads but they hurt!

thick, large and hard metatarsal pads can cause more pain!

thick, large and hard metatarsal pads can cause more pain!

The problem with metatarsal pads is that they must be perfectly placed and of the correct height, thickness and density to be both effective AND comfortable.  Most over the counter metatarsal pads are uncomfortable and therefore painful and ineffective.  It is common for patients to tell me that they have already tried “met” pads and they did not work.  After I inspect their shoe insole it is always the same story.  Large, bulky, hard and ineffective metatarsal pad placed in the wrong location.  No wonder it is not working!  I then choose the correct size, thickness and density for their foot size and body weight followed by a 15-30 minute process of getting the “met” pad expertly placed.  It is always gratifying when the patient instantly reports how much better their foot feels with the correct metatarsal pad placed in the correct location on their insole.

I tried PRP (Platelet Rich Plasma) but it did not work!

PRP is not magic and your injury must be properly rehabilitated

PRP is not magic and your injury must be properly rehabilitated

I can’t explain this but have unfortunately seen it time and again.  The very doctor that is injecting the PRP into the patient has not a clue as to how it actually works.  It’s as if they think they are injecting unicorns and rainbows into the patient.  PRP is simply a direct delivery method to use your own platelets (clotting cells) to inject the torn ligament and stimulate it to heal.  The injury still needs to be protected and your body still has to go through the 3 stages of cellular repair.  That is the inflammatory stage, repair stage and remodel stage.  It is critical that the rehabilitation of the injury is both conservative and effective or you would have simply wasted time and money on an otherwise ineffective treatment.  At our sports injury clinic we outline a highly effective rehabilitation plan for patients following their PRP injection.

My doctor is recommending a cast!  Do I need one?

MBT or Hoka have metatarsal rocker technology

MBT or Hoka have metatarsal rocker technology

A cast is usually not necessary and in my opinion is detrimental.  Immobilization reduces blood flow to the region and is not effective in ligament healing.  What is effective is good circulation and in order to have that you need to have movement.  The reason the doctor is erroneously prescribing the cast is because they are attempting to protect the joint from further injury.  This can usually be accomplished without a cast and instead with specific types of shoes that are built with meta-rocker outsoles.  Two brands that come to mind are MBT and Hoka.  While they may not be the most attractive shoes patients with plantar plate tears often find that they can walk comfortably in these shoes without aggravating their injury.

Plantar plate tears are far more common than most doctors believe.  Patients are usually misdiagnosed or under-diagnosed with anatomical descriptions of their pain such as “Metatarsalgia”.  Metatarsalgia simply means you have pain in your metatarsal region.  It is not descriptive as to exactly what structure is causing you the pain.  Diagnosis such as Metatarsalgia leads patients to minimize their condition and do things that allow it to worsen.  Another common misdiagnosis is Morton’s Neuroma.  A neuroma is a swollen nerve between your metatarsal bones.  When the nerve is pinched it can swell and cause symptoms similar to sciatica, that is, pain will radiate from the site of compression into the toe(s).  This diagnosis is usually given by the most lazy and incompetent of doctors followed by a cortisone injection.  Besides being wickedly painful if it is ineffectual you can usually be sure you were misdiagnosed.

Plantar Plates are very small and small tears are easy to miss even by excellent radiologist

Plantar Plates are very small and small tears are easy to miss even by excellent radiologist

A “clean” MRI will also lead patients down a painful path.  MRI has many flaws.  Besides the images being blurred the person reading it can also make a mistake and either not see it or not read it accurately.  In our office we have a saying, “treat the patient not their MRI”.  It is important to realize that the MRI should be used to support or refute the working diagnosis but not replace a good physical exam and common sense.  We have had many instances where a MRI report said “normal exam” only to get a second read by a different radiologist who then confirmed the presence of the plantar plate tear.  If you are suffering from foot pain, metatarsal pain or already know you have a plantar plate tear contact me at Drrunco@sdri.net or call us 858-268-8525 for an appointment.

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