Bunion Pain: Differential Diagnosis
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A ligament attaches a bone to a bone, and the Plantar Plate is a strong ligament that spans across the forefoot connecting to the joint capsule of each metatarsal head. The primary function of the Plantar Plate is to provide stability to the joints of toes 2-5, and it also acts as an attachment site for the Plantar Fascia. The Plantar Plate is placed under tension from dorsiflexion of the toes in activities such as running or jumping. Still, if these movements are performed to excess, they can overload the Plantar Plate leading to a Plantar Plate Tear.
Patients describe pain on the underside of their foot when walking, standing or running; as the condition deteriorates, this pain can become more constant. Patients report a sensation of walking on their bones as it feels like there is a lack of cushioning underneath their feet. There may be swelling on the top of the forefoot, and patients may notice a “V-Sign” where two of their toes deviate from each other.
It can be painful to walk on uneven surfaces, walking up stairs or hills, running, jumping, dancing or barefoot walking indoors.
Plantar Plate Tears can be caused by a repetitive overload of the Plantar Plate or by a sudden overload of the Plantar Plate. Examples of this are a sudden increase in running volume or changing from rearfoot to forefoot running.
If you have a bunion, this can overload the 2-5th metatarsals, causing excess pressure and an eventual Plantar Plate tear. Irregular metatarsal (toe) lengths can cause excess pressure through the Plantar Plate.
Having a Hammer Toe or poor pronation control can also lead to excess pressure on the Plantar Plate. A history of cortisone injections to the forefoot can weaken the Plantar Plate making it more susceptible to a tear.
A clinical examination from a Podiatrist or a Physical Therapist can identify the presence of a Plantar Plate Tear using clinical tests such as the Digital Lachman’s Test or Churchill sign. (V-sign). If the clinician remains uncertain of the severity of the condition, they might refer you for imaging. An MRI or an Ultrasound scan are best placed for an accurate diagnosis of a Plantar Plate Tear. An ultrasound is more easily accessible and cheaper while an MRI is marginally more accurate but both of them are good options. An x-ray in weight-bearing can be useful for identifying a subluxation and for ruling out other pathologies.
It is worth taking note that in a study of 160 asymptomatic patients, 35% had Plantar Plate Tears.
Mild swelling of the underside and top of the forefoot with tenderness on palpation of the MTPJ
Moderate swelling with a noticeable change in toe position
Swelling of the entire MTPJ with a deviation of the toes and potential subluxation of the joint.
Home treatment for a Plantar Plate Tear should include offloading the foot, icing, anti-inflammatories, no barefoot walking and non-impact exercise. Strapping and Taping can be highly effective at offloading the Plantar Plate Tear and allowing it to heal in an optimal position; therefore, having a consultation with a Physical therapist or a Podiatrist as soon as possible is strongly recommended.
Taping for a Plantar Plate Tear is simple; the affected toe should be placed into plantarflexion using zinc oxide tape. A gait assessment is beneficial to identify any biomechanical reasons that may lead to an overload of the Plantar Plate. The results of this assessment can help a clinician develop a strengthening and stretching rehabilitation protocol for the patient.
Guidance from the clinician on footwear is vital as a stiff, low-profile shoe can reduce the amount of extension of the toes through the gait cycle. A custom insole is helpful to offload the Plantar Plate, and when combined with Taping and stiff shoes, it is a highly effective treatment.
A steroid injection can be beneficial in stubborn cases that fail to improve despite the appropriate care. An injection is generally in the form of a corticosteroid injection, ultrasound–guided into the joint to reduce inflammation levels. Following the injection, a period in a walking boot before weaning out of this into stiff shoes and orthotics can be effective.
The last option for a Plantar Plate Tear is surgery. Several types of surgery can be effective, but we recommend speaking to an orthopaedic consultant about this.
This is not medical advice. We recommend a consultation with a medical professional such as James McCormack. He offers Online Physiotherapy Appointments for £45.
Related Article: Bunions: Symptoms & Treatment