Interesting Case 14 – Plantar Plate Tear

Dr Alex Splatt

44 year old man presents with left forefoot symptoms for several months. No specific traumatic event recalled.

MRI demonstrates disruption of the plantar plate of the second metatarsophalangeal joint at its distal end, lateral aspect. The signal intensity is intermediate, inkeeping with a subacute injury, with poorly defined scar tissue and induration of the surrounding soft tissue. The medial aspect of the plate was intact. Joint alignment was maintained.

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Pathology

The plantar plate is a fibrocartilagenous capsular thickening at the plantar aspect of the metatarsophalangeal and interphalangeal joints. Because of relatively shallow joint space concavity, these structures bear a significant load during joint extension – particularly when running. It is therefore hyperextension injuries of the toe (typically with mild dorsiflexion) which are implicated in plantar plate injury. Acute tears tend to occur most commonly at the first MTPJ (“turf toe”) while degenerative tears are more common at the other plantar plates. Tears tend to start at the distal and lateral aspect of the plate – as it was in our case.

Anatomical specimen demonstrating plantar plate of 3rd MTPJ (black arrow)1

Anatomical specimen demonstrating plantar plate of 3rd MTPJ (black arrow)1

                       

Clinical

“Turf Toe” refers to traumatic injury to the plantar plate of the first metatarsophalangeal joint. It was originally described in American football players, for whom this became a common injury when many of the grounds they played on shifted from natural grass to synthetic turf. The combination of the harder surface under foot and more flexible footwear lead to susceptibility for hyperextension injuries of the forefoot – with frequency of turf toe in professional players quoted up to 30-45%2.

Degenerative tears tend to occur with age, with high heeled, pointed shoes postulated as a contributory factor. These tears tend to affect the 2nd-5th toes more than the 1st and result in symptoms of chronic metatarsalgia.

Management

Management of plantar plate injury depends on severity of the tear. Conservative approaches are favoured when the ligament is strained but intact. Higher grade injuries may require immobilization or surgical repair. Surgery is particularly required in large tears, cases of joint instability or those who fail conservative therapy.

References

 

  1. http://www.thetagoeclinic.co.uk/pages/dislocated_toe.html
  2. Radsource; http://radsource.us/clinic-turf-toe/
  3. Burge, A. Gold, S. Potter, H. Imaging of Sports-Related Midfoot and Forefoot Injuries. Sports Health. 2012 Nov; 4 (6): 518-534.
  4. Crain, J. Phancao, P. Stidham, K. MRI of Turf Toe. Magn Reson Imaging Clin N Am. 2008 Feb; 16(1): 93-103.