Plantar Plate Disorders
The joint of the base of the second toe is a network of many small soft tissue attachments, the bottom of which is called the plantar plate. This joint is commonly subject to attrition. When the plantar plate becomes inflamed it is called capsulitis and also may be referred to as predislocation syndrome.
Capsulitis of the second toe is sometimes caused by trauma, but is usually caused by abnormal foot architecture that alters mechanics over time. A bunion deformity, long second metatarsal bone, or a tight calf are some of the reasons why capsulitis at the base of the second toe can occur.
Usually early on there is pain in the ball of the foot with associated swelling. The condition is progressive as the plantar plate becomes stretched out and may tear, which is appropriately termed a “plantar plate tear.” The side to side support of the joint may also become compromised. The joint becomes unstable and the second toe begins to lift off the ground, which is a hallmark of the condition. In the later stages the toe begins to buckle and forms a stiff, contracted hammertoe. Finally the digit may cross-over the big toe, also known as “Cross-over Toe deformity”.
The diagnosis of this condition is usually diagnosed in clinic. X-rays are taken to evaluate the joint and to determine what may be the cause of the deformity. Injecting dye into the joint and then taking an X-ray (arthrogram) and/or MRI may be used to evaluate for a plantar plate tear.
Capsulitis responds very well to conservative treatment in the early stages and these may include:
- Oral medications-Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help relieve the pain and inflammation.
- Taping/splinting-Using tape or a small toe splint to pull the toe down puts slack in the plantar plate, which can heal once tension is removed.
- Stretching-Calf stretching can be particularly helpful in patient with tight calf muscles.
- Stiff soled shoes, especially those with a rocker bottom can be very helpful.
Custom Orthotics- these devices can be modified to take the pressure off the joint at the base of the second toe.
In the advanced stages of this condition, surgery is often necessary. The combination of procedures differs on an individual basis and is tailored to address each area of pathology. For instance, surgery may involve repairing the plantar plate, as well as addressing the bunion deformity, tight calf muscle, long metatarsal, and/or hammer toe deformity if present. However, even when each of these deformities is corrected, the digit may drift back to cross over toe position especially in the advanced stages of this condition. The specialists at Ankle and Foot Clinics Northwest have significant experience with this deformity and have published research as well as lectured on this topic.
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