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What is a Plantar Plate Tear and How Can It Be Cured?

Updated: Dec 9, 2025

A plantar plate tear is a common but often underdiagnosed cause of forefoot pain, particularly under the second metatarsophalangeal (MTP) joint.

What is the Plantar Plate?

The plantar plate is a thick fibrocartilaginous structure under the ball of the foot that stabilises each of the metatarsophalangeal (MTP) joints, preventing toes from drifting, splaying, or bending too far up (hyperextending) during normal walking and pushing off. It is a shock-absorber and base for the joint capsule, ensuring proper toe alignment and efficient push-off for gait (normal walking). Damage to the plantar plate (typically through an acute or chronic tear) can lead to pain, toe separation (often permanently) and crossover-toes; as the joint fully dislocates in untreated cases. Here's an overview of how to diagnose and treat it.

🩺 Diagnosis of a Plantar Plate Tear

1. Patient History

  • Symptoms: Pain under the ball of the foot, especially beneath the second toe.

  • Onset: May be gradual or following trauma (e.g., tripping, toe hyperextension).

  • Other signs: A feeling of walking on a stone, swelling, instability in the toe.

2. Physical Examination

  • Dorsal drawer test / Lachman test of the toe: Stabilize the metatarsal head and move the proximal phalanx dorsally; excessive movement or pain is suggestive.

  • Toe alignment:

    • Widening of the space between the toes (often between 2nd and 3rd — "V sign")

    • Possible deviation or dorsal elevation of the toe

  • Tenderness: Direct palpation at the plantar aspect of the MTP joint.

3. Imaging

  • Ultrasound: Effective for visualizing tears in the plantar plate.

  • MRI: Gold standard — shows full vs partial thickness tears, degree of retraction, and any associated pathology.

  • X-rays: May show MTP joint subluxation, especially in chronic or severe cases.

💡 Differential Diagnosis

  • Morton's neuroma

  • Capsulitis

  • Stress fracture of metatarsal

  • Synovitis

  • Metatarsalgia

  • Freiberg’s disease

    plantar plate tear

    ✅ Risk Factors for a Plantar Plate Tear

    A plantar plate tear typically results from chronic overload or mechanical stress at the metatarsophalangeal (MTP) joints, especially the second MTP. Here are the most common risk factors: -

    🔹 Biomechanical Risk Factors

    • Long second metatarsal (Morton’s toe): Increases pressure under the second metatarsophalangeal joint.

    • Equinus deformity (limited ankle dorsiflexion): Leads to forefoot overload during walking.

    • Hypermobility (e.g., Ehlers-Danlos syndrome): Leads to instability and ligament laxity.

    • Hallux valgus (bunions): The first ray becomes less functional, shifting load to the second toe.

    • Pes planus (flat feet): Can contribute to poor forefoot mechanics.

    • Forefoot varus: May lead to abnormal pressure distribution.

    🔹 Footwear Factors

    • High heels: Increase forefoot loading.

    • Flexible-soled shoes: Allow too much MTP joint motion.

    • Poor arch support: Fails to stabilize midfoot and rearfoot mechanics.

    🔹 Activity-Related Risk Factors

    • Repetitive forefoot stress: Activities such as running, dancing, or jumping sports.

    • Sudden trauma: Hyperextension injury of the toe, such as stubbing it or catching it on carpet.

    • Occupational strain: Jobs requiring long periods of standing or walking on hard surfaces.

    🔹 Age and Gender

    • Middle-aged to older adults: Degeneration of soft tissue structures increases risk.

    • Women: More commonly affected, possibly due to footwear choices and higher prevalence of hallux abductovalgus (a bunion).

    🔹 Medical and Systemic Factors

    • Inflammatory arthropathies: Rheumatoid arthritis or lupus can weaken ligaments.

    • Obesity: Increases mechanical load across the forefoot.

    • Diabetes: May alter foot mechanics and delay healing.


      🛠️ Treatment of a Plantar Plate Tear

Conservative Management (for mild or partial tears)

  • Activity modification: Reduce activities that stress the forefoot (e.g., running, jumping).

  • Footwear advice:

    • Use shoes with a stiff sole or rocker-bottom to limit metatarsalphalangeal joint motion.

    • Avoid high heels or flexible-soled shoes.

  • Padding and orthoses:

    • Metatarsal pads to offload pressure from the MTP joint.

    • Custom orthotics with offloading support.

  • Strapping:

    • Tape the toe using 10mm zinc oxide tape to stabilise/immobilise the toe joint

  • Anti-inflammatories: NSAIDs e.g. ibuprofen for pain and to address inflammation.

  • Physiotherapy: To address biomechanics, strengthen the intrinsic muscles, and support foot function.

Injections

  • Corticosteroid injections: Can reduce pain but may risk further weakening of the plantar plate if used repeatedly.

Surgical Treatment

Recommended if:

  • Conservative treatment fails (typically over 3–6 months)

  • Full-thickness tears with significant instability or deformity

Surgical options include:

  • Direct repair of the plantar plate (via dorsal or plantar approach)

  • Weil osteotomy (to shorten the metatarsal and reduce pressure)

  • Soft tissue realignment

  • Occasionally, tendon transfers or toe arthroplasty for chronic or severe deformity


    advanced plantar plate tear

🔁 Recovery and Prognosis

  • Conservative care can be effective in early or partial tears.

  • Surgery typically requires 6–12 weeks of recovery with limited weight-bearing.

  • Delayed treatment increases the risk of joint subluxation and persistent toe deformity (e.g., crossover toe).

📝 Summary

Diagnosis is clinical but supported by imaging. Early recognition and offloading are key to preventing progression. Surgical repair may be needed for full-thickness or chronic tears. A multidisciplinary approach (podiatry, orthopaedics, physiotherapy) yields the best outcomes.


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