4/5/2020 Plantar Plate Insufficiency or Rupture (Turf Toe) – RP's Ortho Notes

RP's Ortho Notes

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Plantar Plate Insufficiency or Rupture (Turf Toe)

Anatomy

During normal gait, MTPJ has to sustain more than 40 to 60% off bodyweight, during normal
athletic activities this increases to 2-3 times the bodyweight. During running jump MTPJ sustains
eight times the body weight.
Metatarsophalangeal joint (MTPJ) is statically stabilised by the plantar plate and the collateral
ligaments.
Dynamic stability for the first MTPJ is provided by the short flexor complex, which is composed of
medial and lateral bellies of flexor hallucis brevis, adductor hallucis and abductor hallucis muscles
and the medial and lateral sesamoid bones and their ligaments.
Plantar plate is the trapezoid shaped thickening of the MTPJ capsule at the weight bearing plantar
aspect.
It is a fibrocartilaginous structure that resists hyperextension and provides stability to the MTPJ.
It is the major stabiliser of the MTPJ.
It provides a smooth gliding surface for the flexor tendons inferiorly and metatarsal head
superiorly.
Proximally it is inserted into the metatarsal neck.
Distally to the base of proximal phalanx by medial and lateral longitudinal bundles.
It receives a achment from collateral ligaments, deep transverse metatarsal ligaments and vertical
fibers of plantar aponeurosis.

Mechanism of injury

Degenerative or traumatic rupture of plantar plate is an under-recognised cause of metatarsalgia.

Degenerative rupture of plantar plate especially in the second MTPJ can lead to metatarsalgia
with synovitis, which if untreated progresses to hammer-toe, claw-toe or crossover-toe deformity.
In 2/3rd of cases the second toe is commonly involved as it tis the longest.
Long term use of high heel foot wear may be a cause in older women as it causes chronic
Lesions can cause metatarsalgia, instability, deformity and dislocation.

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4/5/2020 Plantar Plate Insufficiency or Rupture (Turf Toe) – RP's Ortho Notes

Deformity may be in the sagi al plane such as hammertoe and claw toe or coronal plane such as
crossover toe..
During the heel-off and toe-off of stance phase of gait, the MTPJ becomes dorsiflexed. Dorsiflexion
is passively resisted by the plantar plate and actively by the intrinsic musculature.
With insufficiency of plantar plate, dorsal subluxation of MTPJ occurs. The interossei is displaced
dorsally leading to hyperextension of MTPJ. The medially located lumbrical causes adduction
deformity. A enuation of collateral ligaments also contributed to the development of coronal
plane deformity.
Majority of cases have an insidious onset and is seen in sedentary older women.
It can be seen in young athletic males after trauma.
It can also be seen as a secondary deformity in association with hallux valgus, hallux varus, pes
planus and hallux rigidus.
The term Turf Toe introduced by Bowers and Martin in 1976 for injuries of the plantar plate of
first metatarsophalangeal joint (MTPJ) of great toe seen in athletes playing on artificial turfs using
lighter and flexible shoes.
Coughlin coined the term ‘second crossover toe’ in 1987 to describe the coronal plane deformity.
Hyper-dorsiflexion of the MTPJ is the most common mechanism of injury.
Causes distractive forces on the plantar plate, sesamoid complex and toe flexors.
In the big toe, the plantar plate rupture occurs distal to the sesamoids.
Rarely tissue disruption occurs through the sesamoids producing sesamoid fracture.
Injury may be partial or complete. It may extend to the collateral ligaments in presence of varus or
valgus moment.
Hyper-plantarflexion injury is called Sand Toe as it is common in beach volleyball.

Classification

Clinical Classification

Grade Types Physical findings

0 Pain with no Tenderness+, Swelling+, Plantar flexion weak, Drawer –
malalignment
1 Mild Tenderness+, Swelling+, Plantar flexion weak, Mild medial deviation,
malalignment asymmetric space between toes, Drawer+ <50%
2 Moderate Tenderness+, Swelling+, Plantar flexion decreased markedly,
malalignment hyperextension and coronal deformity, Drawer >50%
3 Severe Crossover toe, Hammer toe, Dorsal dislocation
malalignment

MRI Grading

Grade 1: Increased signal intensity with no loss of continuity in the plantar plate.

Grade 2: Bu on hole tear in the weight bearing area.

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4/5/2020 Plantar Plate Insufficiency or Rupture (Turf Toe) – RP's Ortho Notes

Grade 3: Partial rupture involving less than 50% of plantar plate thickness.

Grade 4: Rupture involve more than 50% of plantar plate thickness. Luxation present If collateral
ligaments are torn.

Surgical Grading

0 – Plantar plate a enuation

1 – Transverse tear of distal a achment or mid substance involving less than 50%

2 – Transverse tear involving >50%

3 – Extensive tear which extends to collateral ligament

4 – Extensive tear with dislocation

Differential Diagnosis

Stress fracture
Degenerative arthritis
Inflammatory arthritis
Morton’s neuroma
Frieberg’s infraction
Instability of the lesser MTP joints
Systemic arthritis with involvement of lesser MTP joints
MTP joint synovitis
Synovial cyst formation

Clinical Evaluation

Clinical presentation varies. It ranges from metatarsalgia to frank MTPJ dislocation.

Presentation is usually late.
Plantar plate injuries are frequently missed in the initial examination.
95% present with gradual onset of pain, pain at the 2nd MTPJ, edema at the 2nd MTPJ and
positive MTPJ drawer sign.
Most common sign is localised tenderness over the plantar aspect of second MTPJ.
In the history, ascertain the position of foot, weight bearing status and direction of force at the
time of injury. Ask for the symptoms immediately after injury. Identify the site of pain and the
activities that cause pain.
When examining immediately after trauma, observe for any deformity, ecchymosis, soft tissue
edema, joint effusion and site of tenderness.

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4/5/2020 Plantar Plate Insufficiency or Rupture (Turf Toe) – RP's Ortho Notes

Initially there is no deformity, but later medial deviation is seen, followed by hyperextension and
lastly involved toe crosses over the adjacent toes. Hammertoe deformity of PIPJ develops in
chronic cases.
It may be associated with hammer toe deformity.
End stage of the spectrum of deformities is crossover toe.
MTPJ movements is restricted especially the plantar flexion.
Restriction of plantar flexion can be identified by Paper Pullout Test. A strip of paper is placed
beneath the affected toe tip when the patient is standing. Patient is asked to grasp the paper with
plantar flexion of toe. Inability to grasp is indicative of limitation of plantar flexion.
Stress the MTPJ in valgus and varus to assess the integrity of collateral ligaments. Plantar flex to
assess the dorsal capsule and dorsiflex to assess the plantar plate.
MTPJ Drawer test- Stabilise the metatarsal neck with one hand. Hold the proximal phalanx with
other hand.Try to translate the MTPJ in the dorsal and plantar direction to look for instability.
Normally the proximal phalanx cannot be displaced dorsally. If proximal phalanx can be
displaced with pain, the test is positive and indicates plantar plate tear.
Test the strength of FHL and EHL.

Imaging

Standard AP view, lateral oblique view and lateral view in weight bearing are required. If
sesamoid fracture is suspected, sesamoid view may be necessary.
Look for avulsion fractures, MTPJ subluxation and proximal migration of sesamoids.
Stress lateral view in forced dorsiflexion can be helpful as it can show increased gap between
sesamoids and proximal phalanx base when compared to lateral view in neutral position.
Diagnosis can be confirmed by conventional arthography or MRI.
MRI with non-fat-suppressed T1-weighted or proton density–weighted sequence in three
standard planes and proton density–weighted fat-suppressed or short tau inversion recovery
(STIR) sequences to assess plantar plate and ligaments is needed.
Normal plantar plate has very low signal intensity on MRI and is difficult to differentiate from
overlying flexor tendon.
On the MRI, tears appear as areas of hyperintense signal in the normally low intensity plantar
plate.
Tears are usually located at the distal a achment adjacent to the metatarsal head.
Plantar plate recess, a normal anatomic variant is present in 47% at the distal a achment. It should
not be mistaken for a tear.

Treatment

Most acute injuries are treated conservatively by R.I.C.E ( Rest, Ice, Compression, Elevation)
followed by plaster immobilisation or taping in plantar flexion.
Indications for surgery in chronic
Persistent loss of toe push off strength
Gross instability
Progressive subluxation

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4/5/2020 Plantar Plate Insufficiency or Rupture (Turf Toe) – RP's Ortho Notes

Progressive clawing
Large capsular avulsion with unstable joint
Displaced sesamoid fracture or proximal migration of sesamoids
Traumatic hallux valgus deformity
Failed nonsurgical treatment
Goal of surgery is restoration of anatomy and function
Ideal procedure is plantar plate repair or reconstruction.
Indirect surgical realignment utilising soft tissue release, soft tissue reefing, tendon transfer, and
periarticular osteotomies.
Conservative treatment is usually ineffective in chronic tears with instability.
Non-operative options
Thing of toe to the adjacent digit opposite to the coronal deformity
Foot wear with silicone insole and metatarsal bar.
Foot wear with reduced heel height and wide toe box.
Silicone toe sleeve for hammertoe.
Options for surgical treatment
Plantar approach or dorsal approach with Weil osteotomy for lesser toes.
Medial approach with J shaped plantar extension or combined medial and plantar approach
for big toe.
Postoperative management
Immobilise for 5-7 days. Passive plantar flexion allowed.
Non weight bearing for 4 weeks.
Active plantar flexion allowed after 4 weeks.
Active dorsiflexion permi ed after 8 weeks.
Running started after 3 months.
Playing resumed at 4 months.
Plantar plate repair
Flexor tendon transfer to proximal phalanx indicated in those presenting late with claw toe
deformity.
MTP joint synoviectomy
Soft tissue release with capsular reefing
Phalangeal or metatarsal osteotomy

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