The plantar plate is a strong, fibrous ligament located in the ball of the foot, beneath the metatarsophalangeal (MTP) joints. It plays a crucial role in stabilising the toes and preventing excessive dorsiflexion (upward bending). A plantar plate injury occurs when this ligament is overstretched, partially torn, or completely ruptured. This condition most commonly affects the second toe but can also involve the third and fourth toes. Left untreated, plantar plate injuries can lead to deformities such as hammertoe, claw toe, or crossover toe.
Signs & Symptoms
A plantar plate injury presents with a variety of symptoms, which can vary depending on severity.
- Pain in the ball of the foot – Often described as an aching or bruised sensation, typically localised around the affected MTP joint.
- Swelling (oedema) – Mild to moderate swelling may occur, particularly on the top (dorsal) and bottom (plantar) aspects of the foot.
- Pain with weight-bearing activities – Walking, running (especially forefoot running), dancing, or jumping can increase discomfort.
- Pain relief with rest – Symptoms improve when non-weight bearing.
- Increased pain with certain footwear – High heels, open-toe shoes, and flexible shoes (such as minimalist running shoes) can aggravate symptoms.
- Reduced toe strength – The affected toe may not be able to grip the ground effectively. This can be assessed with the ‘Digital Purchase Test’, where a piece of paper is placed under the toe, and the patient is asked to resist its removal. A weak plantar plate allows the paper to slide out easily.
- Toe deformity – In more advanced cases, the toe may start to lift off the ground (floating toe), drift sideways (Churchill sign), or develop a hammertoe or claw toe appearance.
- Positive Lachman’s or Vertical Stress Test – These tests, performed by a clinician, assess joint stability and are useful in diagnosing plantar plate injuries.
Causes & Contributing Factors
Plantar plate injuries often develop due to repetitive stress rather than a single traumatic event.
Biomechanical Factors
- Forefoot loading – Excessive force through the front of the foot, often seen in forefoot runners, dancers, and athletes engaging in high-impact activities.
- Toe deformities – Conditions like hallux valgus (bunions) can shift weight away from the big toe, increasing stress on the second and third MTP joints.
- Metatarsal length variations – A longer second or third metatarsal (such as Morton’s toe) increases the likelihood of plantar plate overload.
- Tight calf muscles – Limited ankle dorsiflexion can cause compensatory changes in gait, leading to excessive pressure on the forefoot.
Footwear & External Factors
- High heels – Elevating the heel places excessive stress on the forefoot, increasing plantar plate strain.
- Minimalist or flexible shoes – These provide less support and can contribute to excessive dorsiflexion of the MTP joints.
- Barefoot walking on hard surfaces – Lacking shock absorption can increase stress on the plantar plate.
Other Risk Factors
- Ageing – Ligament elasticity decreases with age, making injuries more likely.
- Gender – Women are more commonly affected, possibly due to footwear choices (e.g., high heels).
- Inflammatory conditions – Rheumatoid arthritis and other inflammatory joint diseases can weaken ligaments and contribute to plantar plate injuries.
Imaging & Diagnosis
Accurate diagnosis of plantar plate injuries often requires imaging, as clinical tests alone may not detect the severity of the injury.
X-ray
- Weight-bearing X-rays (lateral or oblique views) may show dorsal subluxation of the proximal phalanx on the metatarsal head.
- An anterior-posterior X-ray can reveal a transverse toe deformity.
- X-rays help rule out other causes of forefoot pain, such as fractures or arthritis.
Ultrasound
- A dynamic and cost-effective imaging option for diagnosing plantar plate injuries.
- Allows real-time assessment of ligament integrity and MTP joint stability.
- Operator-dependent, meaning accuracy can vary between practitioners.
- Sensitivity: ~93%, Specificity: ~33%.
MRI (Magnetic Resonance Imaging)
- The most reliable imaging method for diagnosing plantar plate injuries, providing a comprehensive view of soft tissue structures.
- Highly sensitive for detecting partial or full-thickness tears.
- Sensitivity: ~95%, Specificity: ~54%.
- A short tau inversion recovery (STIR) sequence can increase sensitivity and specificity for detecting plantar plate injuries.
- MRI is more expensive than ultrasound but provides a clearer picture of surrounding structures.
Clinical Considerations in Imaging
- One study found that 35% of asymptomatic individuals had plantar plate injuries, raising questions about whether all diagnosed cases require treatment.
- Imaging should be used in conjunction with clinical symptoms to guide management decisions.
Grading of Plantar Plate Injuries
Several classification systems exist to assess the severity of plantar plate injuries. The two most widely used are:
Thompson & Hamilton Classification
- Stage 0 – No visible displacement of the toe.
- Stage 1 – Subluxation (partial dislocation) of the joint is possible, but the toe remains in place.
- Stage 2 – The toe can be fully dislocated but remains reducible (can be put back into place).
- Stage 3 – The toe is in a fixed dislocated position and cannot be realigned manually.
Yu & Judge Classification
- Stage 1 – Mild swelling and tenderness with no visible deformity.
- Stage 2 – Moderate swelling with noticeable deviation of the toe.
- Stage 3 – Severe swelling with significant toe displacement or dislocation, often leading to permanent deformity.
Prognosis
The prognosis for plantar plate injuries depends on the severity of the tear and the effectiveness of treatment.
- Mild to moderate injuries (Stages 0–1) – Generally respond well to conservative treatment, with symptoms improving over several months.
- Moderate to severe injuries (Stages 2–3) – May require more intensive management, including prolonged offloading, orthotics, or surgical intervention.
- Chronic cases with deformity – If left untreated, persistent instability can lead to hammertoe, claw toe, or crossover toe, which may require surgical correction.
Return to normal activities varies:
- Mild cases – 6–12 weeks with appropriate rehabilitation.
- Moderate cases – 3–6 months.
- Severe cases or post-surgical recovery – 6–12 months before full return to high-impact activities.
Treatment
The primary goal of treatment is to offload the plantar plate and promote healing while maintaining toe function.
Conservative Management
- Activity modification – Avoid barefoot walking and high-impact activities for at least six weeks.
- Footwear advice – Use stiff-soled shoes or rocker-bottom shoes to reduce toe dorsiflexion. High heels and flexible shoes should be avoided.
- Strapping & taping – Using rigid tape (such as zinc oxide tape) to hold the toe in a plantarflexed position can reduce strain. Tape should be changed every 72 hours.
- Orthotics – Metatarsal pads or domes help redistribute pressure away from the affected MTP joint. Carbon fibre insoles can provide additional support.
Physiotherapy in Conservative Management
Physiotherapy plays a key role in rehabilitation by restoring foot function, reducing pain, and preventing recurrence. A physiotherapy program should include:
1. Strengthening Exercises
- Intrinsic foot muscles – Exercises such as toe curls, marble pickups, and short foot exercises strengthen the small stabilising muscles of the foot.
- Toe control exercises – Toe resistance band exercises improve strength in the affected toe.
- Calf strengthening – Seated or standing heel raises to enhance calf and foot strength.
2. Stretching & Mobility
- Calf stretching – Reducing tightness in the gastrocnemius and soleus muscles prevents compensatory forefoot overload.
- Toe mobilisation – Gentle manual mobilisation of the MTP joint to maintain flexibility.
3. Gait Retraining
- Modifying foot strike patterns – Encouraging midfoot or rearfoot striking can reduce forefoot stress.
- Stride adjustments – Reducing stride length can lower ground reaction forces.
4. Balance & Proprioception
- Single-leg stance exercises – Improves foot stability and control.
- Wobble board or BOSU ball training – Enhances dynamic foot and ankle stability.
Regular physiotherapy reviews help monitor progress and adjust the rehabilitation program as needed.
Surgical Management
Surgery is recommended for:
- Full-thickness plantar plate tears.
- Persistent pain despite conservative treatment.
- Progressive toe deformity.
Post-surgical rehabilitation follows a structured program with gradual return to activity over 6–12 months.
By incorporating physiotherapy into conservative management, patients can strengthen the foot, improve biomechanics, and reduce the risk of future injuries.
Information is provided for educational purposes only. Always consult your physiotherapist or other health professional.
References
Kussl, S., Schöffmann, S., Pezzei, C., Bock, F., Bale, R., Hohenberger, G., & Dammerer, D. (2023). Plantar plate tears of the lesser toes: A review of diagnosis and treatment options. Journal of Orthopaedics and Traumatology, 24(1), 6. https://doi.org/10.1186/s10195-024-00814-x
Majeed, H., Alsousou, J., & Hassaan, S. (2024). Plantar plate pathology: An update on diagnosis and management. Foot & Ankle Surgery: Techniques, Reports & Cases, 4(1), 100101. https://doi.org/10.1016/j.fastrc.2024.100101
Waizy, H., & Keller, K. (2022). Diagnosis and treatment of plantar plate tears. Journal of Clinical Medicine, 11(1), 234. https://doi.org/10.3390/jcm11010234
