Today we welcome back top podiatrist Nick Knight to the site. He’s kindly written a great follow up piece to his previous blogs on plantar plate injuries and foot orthoses for the treatment of plantar plate injuries. Nick is featured in our RunningPhysio Recommends series and has written some brilliant articles for us in the past! Check out Nick’s website and be sure to follow him on Twitter via @NKSportsPod.
When we look around the literature for treatment of plantar plate injuries, there is a large amount of work with regarding the surgical management plantar plate injuries, however very little with regards to the Conservative management. Currently there are only 2 papers published, both were single case studies.
First we had Ojofeitimi, Bronner, & Becica (2016) looking at treatment of a professional dancer with a 2nd MPTJ plantar plate injury, with 6 and 12 month follow-up and at 12 months the dancer was still competing at their elite level on 16 weeks and 37 physical therapy sessions. The authors described 3 phases to the rehabilitation process.
Phase 1 : protection – lasting approximately 2 weeks
This was focusing on reducing the pain and protecting the 2nd MTPJ, no foot exercises, with the focus on more proximal control work. There was no dancing or benefit walking and the patient was in a post-operative boot.
Phase 2: restricted duty – lasting approximately 2 weeks
Some foot doming and towel curl exercises were introduced along with increasingly proximal control work. The only activity was barre work, along with the weaning out of the post-operative boot into trainers. To help protect the toe strapping was used.
Phase 3: – modified duty/return to performance
Resistance band toe flexion exercises were added in this phase alongside increasing the proximal control work and reducing the padding and strapping over time. A return to all dance activity was achieved by the end of 16 weeks.
Image source: Ojofeitimi et al. (2016) *open access*
The 2nd case study by (Jordan, Thomas, & Fischer, 2017) which involved offloading in a surgical boot, with serial MRIs over a one year period. They reported, “full clinical restoration of function and radiologic evidence of healing”.
As we can see there is a limited literature around conservative management, however I do believe that conservative management of plantar plate injuries can be effective in clinic. The majority of plantar plate injuries we tend to see in clinic are related to runners and dancers.
We are currently in the process of auditing our own data in clinic to see how effective our conservative plantar plate treatment regime is. Having a quick look at this data, the time for return back to play/activity if you just have it isolated plantar plate injury is 10 – 14 weeks, however if you have a pre-existing lower limb pathology, ranging from osteoarthritis, hallux valgus, tendinopathy the return to play/activity timescale ranges from 12 weeks up to 49 weeks. We do plan to publish, we are still collecting data so we can try and have a look a case series, over a range of sports and activities, also with follow-up, to check activity levels after treatment.
I am now going to speak about the protocol that we use in clinic to help try manage plantar plate injuries. I will mention the use of foot orthoses, however if you want a more in-depth blog around the use of foot orthoses for managing and helping plantar plate injuries, please see my previous article. Also if you want an overview of plantar plate injuries see the first blog in this series.
It is also worth noting not all of the plantar plate injuries that I see in clinic are diagnosed using ultrasound or MRI, and I do not send all of my patients for imaging, as research (Klien et al 2013) has shown that pain, positive digital Lachmans (anterior draw) test and minor swelling, has been shown to identify 95% of plantar plate injuries. The majority of plantar plate injuries that we see in clinic are chronic injuries, rather than acute tears.
To help with our own audit data, we were using the digital purchase toe strength test, to help assess weight-bearing plantar flexion strength of the toes. However, more recently in clinic we are trying to quantify strength using a handheld dynamometer and are currently testing different ways to assess this.
Like with all rehabilitation programme I explain to our patients that there are 3 – 4 stages. Firstly we need to help reduce the pain, then increase strength then help return back to their sport/activity. If there has been an acute tear, we also try a period of immobilisation. However we’ll know that it is not black-and-white during the rehabilitation stages but for the purpose of the blog, as I know both patients and clinicians read this I will explain my 3 stages as pain reduction, increase strength and return to play.
Stage 1 – Pain reduction
As part of the offloading process, I do have strict advice of no barefoot walking for around 4 – 6 weeks, depending on symptoms. I used to use a lot of carbon lining with a forefoot rocker, to help sagittal plane function and reduce flexion of the lesser MTPJs during propulsion, as this is normally the phase of the gait cycle that aggravates most plantar plate injuries.
Hoka have released their Carbon X trainer, which I have found gives really good results, with it helping to reduce pain and get people back to walking earlier. It is also worth noting that new balance have just released their Fuel Cell TC shoe, however the rocker doesn’t look as much as the Carbon X. During writing this we are in the middle of the COVID-19 lockdown in the UK and I have not been able to get hold of a pair yet, I am aware that Nike have their 4% and Zoom fly trainer but I found the midsole of these trainers to be too narrow.
I also recommend patients to tape their toe in a plantar flexed position, changing the tape on a daily basis.
Also, as mentioned in the previous plantar plate blogs, this is the stage where I will issue foot orthoses if required.
From an exercise perspective, I get patients to start working on increasing foot intrinsic muscle strength by doing standing foot shortening exercises, or as I call them toe push-ups.
I often start lesser toe flexion exercises with a low resistance band, however if too painful, I will start with no band.
I also use this time to start working on any proximal strength requirements.
Stage 2 – Increase Strength
As already mentioned you can see that there is no clear delineation between stage I and stage II. As if we start to increase strength we are still going to have possibly a couple of weeks of taping or no barefoot walking remaining.
As we start to now focus on increasing the strength, we start to increase the resistance on the band loops, for me it is important that the RPE (rate of perceived discussion) is kept 7/10. Once someone can do 15 toe flexion exercises comfortably we move to a tougher resistance band progress them up to the highest level of resistance available.
Once the patient is able to use the highest resistance band on the toe flexion exercises I start testing my patients ability to do calf raises. I start double legs in shoes, either the Hoka Carbon X or with the carbon lining, just to help with confidence. This can be quite a fearful exercise for patients to do as they know previously that this has hurt. Then as symptoms and strength improve we progress to double leg barefoot then to single leg barefoot. This is the one exercise that I find we can get a flareup of pain so I’m quite cautious in the introduction of this, however I do believe it’s extremely important that our patients are doing this, as the motion of going up onto your toes is involved in walking and the majority of sports, in particular running.
I keep my patients doing the toe push-up exercises, they tend to do around 3 – 500 in total per day, broken into batches of 20-30, I let my patients do them with shoes on and integrate them into their day.
I also introduce balance work using a wobble question, I did used to try and start this earlier, however I was finding that this was flaring up the pain.
Stage 3 – Return to play / activity
By this time my patients have normally stopped taping the toe completely, and we have weaned them off the carbon lining if we are using one.
I view this stage as really trying to build the capacity up to allow the patient to return back to their activity and sport. From an exercise viewpoint we are still focusing on the toe flexion exercises with the band loops and quite often by this stage I’m getting some patients to double bands up to increase the strength even further. We may start to add some plyometric exercises and progress to barefoot single leg calf raises on the edge of a step with some additional weight.
Then, like any rehabilitation programme we advise on a graded return back to their activity. I do normally keep the patient in their orthoses whilst they are getting back to their activity in sport, however we are finding that patients who were using the Hoka Carbon X, we can look to wean off the foot orthoses once they are back to their full level of activity in sport, or just use the orthoses for intense training periods. This is really individual and we have not found a particular pattern, so on removing the foot orthoses I’m really guided by my patient’s feedback. We do have some patients who do require the foot orthoses longer-term, from my experience these would tend to be the patients that have a 1st MTPJs pathology, as this would have played a large part in why the plantar plate would have been injured in the first place.
We also then repeat our strength testing and every time we have found a increase in strength through the plantar flexors. I do believe this helps to really empower the patient to show they have made progress, they are stronger and they are back to their activity.
Finally, and probably most importantly is discussing a maintenance programme. We know it is extremely important that the patients still continue with exercises to maintain their new levels strength and to help possible try reduce the risk of further injury. I still advise the patient to keep some tape and the carbon linings, which they can use if they have a flareup, however with everyone going through the process they report that they feel empowered to manage this themselves going forward.
As you can see there are no definitive timelines as to when to move on from each stage. The process that we run in our clinic is that, on average, patients are seen for 5 sessions over a period of 3 – 4 months, with the length between each appointment gradually increasing.
Taking a quick glance at my data in the patients with plantar plate injuries we have managed in this way, the majority of them are still doing the same level of activity if not more 6 months down the line and have not reinjured.
As I mentioned at the beginning of the blog we do intend to try and publish our data, however we are hoping to get more long-term data first. Then we can try to paint a picture and suggest a possible conservative management protocol for managing plantar plate injuries conservatively, as there is very little evidence to guide us currently.
I do think there is place for conservative management of plantar plate injuries and I think it can be quite successful. For me the key points are in the early stages to offload using a carbon lining or shoe such as Hoka carbon X which have proven to be very beneficial to my patients.
We really do need to focus the rehabilitation side of things on working on the intrinsic muscles and toe flexors and then most importantly towards the middle and end of the programme ensuring that people can do calf raises and plyometrics. From experience if there is going to be a flareup it is normally when we start introducing the calf raise work, so always try and start shod and then progress guide by patient response.
Jordan, M., Thomas, M., & Fischer, W. (2017). Nonoperative Treatment of a Lesser Toe Plantar Plate Tear with Serial MRI Follow-up: A Case Report. The Journal of Foot and Ankle Surgery, 56(4), 857-861. doi:10.1053/j.jfas.2017.02.016
Ojofeitimi, S., Bronner, S., & Becica, L. (2016). Conservative Management of Second Metatarsophalangeal Joint Instability in a Professional Dancer: A Case Report. Journal of Orthopaedic & Sports Physical Therapy, 46(2), 114-123. doi:10.2519/jospt.2016.5824
Klein E E, Weil L, Weil L S, Coughlin M J and Knight J. Clinical Examination of Plantar Plate Abnormality: A Diagnostic Perspective Foot Ankle Int 1071100712471825, first published on January 14, 2013 doi:10.1177/1071100712471825