Conservative Management of Chronic Multi-Digit Plantar Plate Pathology: A Case Study

by | Oct 13, 2025 | Blog

By James Babinsky

BACKGROUND

Plantar plate pathology is one of the most encountered causes of plantar forefoot pain. Plantar plate tears have been reported in up to 40% of cases with metatarsalgia1.

The plantar plate is a fibrocartilage structure that acts as one of the primary static stabilizers of the metatarsophalangeal (MTP) joints ). It is composed primarily of type 1 collagen fibers, which allow it to resist tension and compression forces at the MTP joint1. The plantar plate runs from the periosteum of the metatarsal neck to the base of the proximal phalanx. There are two collateral ligaments that attach to the plantar plate on either side of the MTP joint. The combination of the plantar plate and collaterals provides stability in the sagittal and transverse planes. Interossei tendons, lumbricals, and flexor tendon sheaths also attach to the plantar plate2.

Several important functions are attributed to the plantar plate. It primarily provides static stability to the MTP joint. It acts to reduce compressive forces at the MTP joint in weightbearing. It also helps to maintain the windlass mechanism and resist tensile forces caused by this mechanism. As the plantar plate is the primary stabilizing structure of the MTP joint, it is reported as the first to fail in cases of MTP pathology1 ,2.

The second MTP joint is the most common area for plantar plate injury1. Cases of plantar plate injury have been reported at much lower incidence at digits 3-5. Cases of digit 5 appear very rare and were not mentioned in available literature.

Most often, plantar plate pathology is chronic, degenerative, and progressive, although acute injury is possible. As pathology progresses, there is a loss of sagittal plane stability at the MTP joint, which leads to dorsal subluxation or dislocation at the MTP joint. This often leads to transverse and sagittal plane deformities, such as hammertoes and toe crossover1, 2.

Patients typically present with localized pain at the plantar aspect of the MTP joint. Pain is often produced during the propulsion phase of gait, and with direct pressure or palpation at the joint. The modified Lachman test or drawer test is recommended for diagnosing MTP joint instability. It has 80% sensitivity and 99.8% specificity1, 2. Three-view weight bearing radiographs can help with the diagnosis, as they demonstrate deviations and deformity in transverse and sagittal planes. MRI or ultrasound is needed to visualize the plantar plate2.

Plantar plate injuries are typically managed surgically1,2. There is limited evidence available regarding conservative management of plantar plate injury. Currently, there are only case studies available for evidence of successful conservative management. In two case studies available, the authors reported good outcomes at one year of treatment, with patients being able to return to high levels of activity3, 4. There is no clearly defined protocol for non-operative management of plantar plate tears. It has been stated that conservative care will not allow for anatomic repair of the fibrocartilaginous plantar plate. It has also been stated that conservative care will be most likely to be successful with lower grades of injury and earlier in the progression1, 2.

CASE BACKGROUND

Our patient presented with a chronic history of metatarsalgia and plantar foot pain. The patient in this case was a 35-year-old female with a history of 15 years of left plantar foot pain. She is a highly active individual, who participated in hiking, skiing, working as an outdoor guide (kayak, hiking) and various forms of dancing. She reported that her symptoms had waxed and waned over the 15-year period. She had one point at the worst of her symptoms where her foot was chronically swollen, with severe pain levels and hyperesthesia. She reported she had neuropathic pain at this point, and stated that there was a period where she could not tolerate any light touch to the affected area. She described feeling like she was stepping on a rock during weightbearing or activity, which would cause sharp, shooting pain in the area of the middle to lateral MTP joints.

Her treatment included two steroid injections shortly after the onset of symptoms, 15 years ago. She estimates the height of her symptoms were at 8-9 years after onset. She had completed prior courses of physical therapy, massage therapy, and acupuncture. She felt that acupuncture had been very helpful when she was dealing with severe pain and neuropathic symptoms.

Her most recent MRI was done nearly 14 years after the onset of pathology. The report detailed the following:

  • First and second ray were unremarkable.
  • Mild dorsal subluxation of 3rd ray with mild bone marrow edema and small joint effusion.
  • High grade dorsal subluxation of 4th and 5th ray, with moderate to large joint effusion, and bone marrow edema.
  • The 4th and 5th rays did not have a present plantar plate, and were likely ruptured.

Her history included psoriasis, which other providers had noted may have caused the rupture of the plantar plate.

When she presented to our office, the patient had consulted with multiple surgeons who were recommending surgical management of her case. Options included various plantar plate repair techniques, and most recommended fusion of the MTP joints as well. She had requested a trial of conservative management with the goal of avoiding surgery.

CLINICAL EXAM FINDINGS

At her initial evaluation, she described her symptoms as a soreness at the base of digits 3-5. She was sensitive to pressure/compression of digits (such as with ski boots) and pressure to the base of toes. Symptoms were worse with walking barefoot. She stated that her symptoms depended on activity, and she had periods with no symptoms when avoiding provocative activities.

Her exam showed the following:

  • Severe hammer toe deformity at digits 3-5
  • Visible redness and swelling at digits 3-5
  • Severe medial arch collapse in weightbearing, with limited weight bearing/ground contact along the lateral column of the foot and digits 3-5
  • Mild limits of motion at the subtalar joint
  • Mild limit of plantar flexion at the talocrural joint, normal dorsiflexion motion which was symmetrical with the unaffected side
  • Hypermobility of the midtarsal joints, most notably with combined motions of pronation
  • Moderate laxity of the lateral ankle ligaments with inversion/supination stress testing and anterior drawer testing
  • Positive drawer testing with increased translation at the MTP joints of digits 2-5
  • Severely limited strength of the toe flexors at digits 3-5, with inability to perform digital purchase test
  • Fair calf strength with single leg heel raise, with plantar foot pain
  • 6/9 on the Beighton scale
  • Knee valgus collapse with functional movements such as squatting and step-up/down

TREATMENT PROTOCOL

Her treatment plan was as follows:

  • She was recommended to use rocker bottom shoes at all times to decrease loading on the MTP joints
  • She was recommended to use a dynamic ankle brace to address lateral ligament laxity during all weightbearing activity. It has been shown that loss of lateral ligament function leads to slippage of the talus anteriorly in the mortise and excessive internal rotation of the talus. This finding was thought to contribute to the observed instability in the kinetic chain of the foot and ankle, including the MTP joints.
  • She was prescribed insoles which had a metatarsal pad and sufficient medial arch support to correct her resting foot posture in weightbearing
  • She was initially recommended to avoid plyometric type movements, such as her normal dancing activity, to allow for effusion and synovitis of the MTP joints to decrease
  • She was recommended to avoid all barefoot activity
  • She was treated with manual therapy techniques to address painful myofascial findings in the plantar foot and lower limb. Joint traction and low grade mobilization for MTP joint flexion were used at digits 3-5.
  • She was given toe yoga and short foot exercise progressions working on foot tripod positioning, intrinsic muscle strengthening, and sensorimotor control
  • Hip abductor and external rotation strengthening, and motor control exercises were incorporated to help address valgus dysfunctions observed

RESULTS

Results:

  • She was able to achieve a normal foot tripod position in weightbearing and single leg stance positions with the usage of prescribed brace and insoles.
  • She was able to gradually increase her activity level, resuming previously irritating activities as her symptoms had decreased. She was able to gradually return to more strenuous activities, eventually returning to full intensity and volume without symptom provocation.
  • She reported a large improvement in her pain levels, functional abilities, and activity tolerance at her 5th visit, which was 13 weeks after beginning treatment
  • At her most recent follow-up at 8 months, she had been able to resume all activities at or near full intensity, including dance, running, and strenuous hiking/backpacking trips. She reported that she was able to complete all these activities with minimal to no irritation. She would experience irritation if she did not use shoes with a rocker bottom. She was diligent with her usage of the prescribed ankle brace and orthotics. She still experienced swelling in the foot, which was thought to be related to pooling distal to the brace; the swelling was global distal to the brace and resolved quickly when the brace was removed. If symptoms were provoked, she reported 1-2 days of mild soreness before returning to baseline. At this point she was able to regulate her symptoms based on activity level/footwear and had minimal pain at baseline. She completed a LEFS with a score of 71, consistent with minimal limitations. She only reported limitations due to pain with activities involving running and hopping.

DISCUSSION

Based on the review of the literature, it is unique to see plantar plate pathology at digits 3-5, especially digit 5. Although she had instability findings at the 2nd MTP, which is cited as being the most common, her primary symptoms were at digits 4-5. This case is also unique in that it offers a longer-term perspective on plantar plate tears and healing. The two available case studies were related to acute pain and followed the patients over 1-2 years. In our case the patient dealt with pain for 15 years. Several studies cite that relative healing can occur with plantar plate pathology if fibrocartilage scar tissue is able to form and stabilize the MTP joint1, 4. It is likely that our patient had reached this point due to the length of her symptoms. Her ability to return to a high level of activity suggests that good functional outcomes can be achieved with conservative care. This is consistent with other studies which report that a successful return to activity and satisfactory functional outcomes with conservative care may take one year or longer to achieve3, 4.

One unique component of the treatment strategy was to use an ankle brace to help stabilize the talocrural joint in the presence of lateral ligament laxity.  This helped to prevent slippage of the tibia on the talus and compensatory changes in the mid and forefoot positioning 5. This additional stability was needed to fully correct her resting foot position, as she still showed significant rearfoot eversion and medial arch collapse with her orthosis. The usage of the ankle brace aligns with clinical practice guidelines, suggesting the usage of an ankle brace for all individuals who have suffered an inversion sprain6.

Several factors which are unique to this case include the patient’s score of 6/9 on the Beighton score, showing a global increase in mobility. She also dealt with psoriasis, and occasionally psoriatic flare-ups, although she reported it had been well controlled upon presentation to our clinic. Both of these systemic factors may have contributed to a unique variation of plantar plate pathology, degenerative changes, and the observed “absence of plantar plate” on MRI findings.

TREATMENT TIMELINE/OVERVIEW

  1. At initial evaluation she was given initial advice on footwear and orthotics. She was recommended to wear stiff shoes with significant support along the medial arch. She was told to avoid minimalist type footwear, and all barefoot walking. She was advised to minimize the amount of compression from tight footwear at this time, such as ski boots, as it was likely perpetuating synovitis and joint irritation. She was given initial foot intrinsic strengthening exercises in a non-weightbearing position.
  2. The patient was seen three weeks after initial evaluation. She reported small improvements based on initial recommendations. Visit 2 consisted of a more detailed assessment of the patient’s footwear and standing foot position. We reviewed her footwear and recommended shoes which had a rocker bottom in order to unload the MTP joints. The orthotics she was using did not have enough arch support to prevent medial arch collapse, and they did not have a metatarsal pad. She was given a specific orthotic recommendation (Aetrex insoles) which provided a metatarsal pad and significant medial arch support. She was also advised to use a Bauerfeind ankle brace to stabilize the talocrural joint. She was educated to wear the brace with all weightbearing. With the addition of the ankle brace and insoles, her standing foot position improved notably, with decreased medial arch collapse, minimal calcaneal eversion, and improved MTPJ positioning. Manual therapy was introduced with light traction and mobilization towards flexion at the affected MTP joints.
  3. Patient was seen for a third visit three weeks later. She had bought the prescribed orthotic and brace. She had increased her activity and had been doing a fair amount of hiking and skiing. She reported moderate pain in the foot/toes, worst after Nordic skiing. Treatment again reviewed her foot position with the brace and orthotics. She still showed medial arch collapse, so further support was added with a small heel wedge placed on the medial side of the orthotic. She also showed no space between the 4th and 5th digits, so a small toe spacer was added. Treatment moved more into functional movement testing. She showed a good ability to maintain her foot positioning in single stance positions, with the usage of her orthotic and ankle brace. She did show a tendency to collapse medially into knee valgus with squatting and step-ups. Her home plan was updated to include hip abductor and external rotator strengthening exercises, such as a squat with band resistance at the knees.
  4. She was seen for the 4th visit in another three weeks. She reported that she had been consistent with the prescribed recommendations for footwear and orthotics. She reported being able to dance without foot/toe irritation (the patient participated in a variation of folk dancing which involved low level plyometric type movements). Treatment used soft tissue treatment for the plantar foot musculature, and joint mobilization for the MTP joints. Her lateral hip was also addressed with soft tissue treatment due to complaints of soreness, and the observed deficits in frontal plane control previously. Her foot intrinsic strengthening exercises were progressed toward weightbearing specific exercises, with emphasis on maintaining arch positioning with added challenge to the medial and lateral arches.
  5. Her 5th visit was one month later. At this point she reported significant improvements in her activity tolerance, stating that she had been able to resume more strenuous hiking with minimal foot/toe symptoms. She had also been able to continue her dancing. Treatment continued with similar manual therapy techniques from visit 4, and progression/variations on her intrinsic strengthening and arch control.
  6. Her 6th visit was two weeks later. At this time she was able to continue to increase her activity, with sustained hiking and long periods of dance; she performed 3 days of consecutive dancing with 6 hours of dancing each day. She reported minimal discomfort anywhere in the lower extremities.
  7. Her 7th visit was 6 weeks later. She reported much more strenuous and prolonged hiking. She stated that she had noticed more swelling in her foot, primarily at the base of her toes. She still had minimal pain. At this point she was having more global soreness through the local soft tissue, such as her gastroc/soleus complex.
  8. Her 8th visit was 8 months after beginning treatment. She had continued to progress her hiking, and had recently completed a 5 day backpacking trip without irritation. She reported some foot pain after trying to hike in boots without a rocker bottom. She presented with moderate swelling in the foot and tenderness at the plantar aspect of the MTPJ of digits 3-5.

References

  1. 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.
  2. Jastifer, J. R. (2022). Plantar Plate Repair for Metatarsophalangeal Joint Instability of the Lesser Toes. Orthopedic Clinics, 53(3), 349-359.
  3. 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.
  4. 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.
  5. Phelps, V. (2024). Ankle and Foot Pathoanatomy [PowerPoint Slides]. International Academy of Orthopedic Medicine.
  6. Martin, R. L., Davenport, T. E., Fraser, J. J., Sawdon-Bea, J., Carcia, C. R., Carroll, L. A., … & Carreira, D. (2021). Ankle stability and movement coordination impairments: lateral ankle ligament sprains revision 2021: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American physical therapy association. Journal of Orthopaedic & Sports Physical Therapy, 51(4), CPG1-CPG80.