Can a Plantar Plate Tear Be Repaired Non-surgically?
This is a remarkable paper by an orthopaedic foot surgeon and radiologist from Augsburg, Germany, that treated and followed one of their own hospital's nurses that had a plantar plate tear through a series of high-resolution MRI scans over a year's period of time. The results were very impressive.
A 48-year-old female intensive care nurse at their hospital had injured her right forefoot in a water skiing accident in September 2013. She described immediate pain at the base of her second toe, followed by localized swelling. She was evaluated by the orthopaedic surgeon for the first time in March 2014, 6 months after the injury had occurred.. She presented with pain on palpation over the plantar aspect of the base of the basal phalanx of her second toe on her right foot. Compared with the contralateral side, the second metatarsophalangeal joint (MPJ) was unstable with a positive dorsal drawer test. Complete dislocation of the joint was not observed during the drawer test. Swelling was also present on the dorsal aspect of the second MPJ joint. The patient described no history of a previous episode of forefoot pain before the water skiing accident.
High-resolution MRI scans at the first evaluation revealed a tear of the plantar plate of the second MPJ joint (see serial MRI images below). After a discussion of the treatment options, the patient decided on a nonoperative treatment plan for the pathology in her right foot. A therapeutic regimen was initiated consisting of taping the second toe in 10 degrees of plantarflexion and a forefoot unloading shoe with a selective cushioning insole for the second MPJ joint. This insole could accommodate a slightly plantarflexed second toe by an additional modification that reduced its height compared with the areas for contact with the other toes (Darco shoe).
The patient was also instructed in the taping technique, and she was asked to wear the shoe full time. Digital plantarflexion taping was used for 6 months. Using this taping, the patient was able to work in her normal job. She was re-evaluated clinically at 3, 6, 8, and 12 months. Follow-up MRI scans were also performed at 3, 8, and 12 months (i.e. 4 sets of MRI scans total) after her first clinical presentation. All MRI scans were performed and read by the same musculoskeletal radiologist and all clinical examinations were performed by the same orthopaedic surgeon.
When presenting at 3 months after the initiation of treatment, the patient reported only a mild overall improvement in her symptoms. She could walk with the forefoot unloading shoe but felt unable to walk with standard footwear. The clinical evaluation revealed that the joint was more stable and less swollen and the plantar plate was less painful on palpation compared with at the initial examination. Also, the toe was noted have returned to a physiologic position compared with the slight hammer toe and about 10-15 degrees of dorsiflexion at the beginning of treatment.
At the evaluation 6 months after the initiation of treatment, she reported less pain and her clinical symptoms were similar to those she had described at the 3-month follow-up visit, although she described further reduced tenderness over the plantar aspect of the base of the proximal phalanx of the second toe. The patient also reported that she had worn both shoe and tape consistently. She was able to work full time during the entire 6-month treatment period.
For the second 6 months, the treatment was changed to a stiff-soled shoe with special insoles offloading the second MTP joint, and no further taping was recommended. The patient was instructed to continue to avoid recreational sports activities. No MRI was taken at the 6-month follow-up point. At 8 months after the initiation of nonoperative treatment, the patient reported having occasional, slight pain in the area of the base of the second toe but was pain-free otherwise. Gait examination revealed a non-antalgic gait with normal stride length with the second digit being stable on dorsal drawer testing and not painful on palpation. The toe showed a physiologic alignment, and the paper-pull out test for the previously injured second toe was normal.
Additional follow-up MRI scans revealed further improvement in the structural integrity of the plantar plate of the second MTP joint. At this point, moreover, the patient was allowed to resume sports activities and to wear normal shoes. At the final follow-up examination, 12 months after initiation of the nonoperative treatment protocol, the patient reported that she was comfortably participating in sports at a level comparable to that of her pre-injured state, approximately 18 months earlier. She experienced no more pain in the ball of her foot, and the results of the clinical examination were comparable with those observed for the contralateral, uninjured foot, neither of which displayed edema, pain, or joint instability. A final follow-up MRI scan was obtained, which revealed further evidence of repair of the plantar plate.
In conclusion:
this patient initially presented with pain at the plantar base of the basal phalanx, local edema, a positive dorsal drawer sign, and a mild hammer toe deformity, all typical symptoms with a high suspicion of a tear of the plantar plate, which was also strongly suggested by the MRI findings. The clinical and MRI follow-up for a 12-month period showed that her plantar plate rupture healed clinically and on MRI, with full function restored. One interesting aspect in this case report was the delayed onset of therapy (6 months after the initial accident), which suggests a satisfactory result can be achieved even after a period of chronic rupture.
Reference:
Jordan M, Thomas M, Fischer W: Nonoperative treatment of a lesser toe plantar plate tear with serial MRI follow-up: a case report. J Foot Ankle Surgery. 56(4):857-861, 2017
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