Plantar plate tears disrupt the tough, fibrous plate-like structure that sits under the metatarsal phalangeal joints in the ball of the foot. These joints are like the “knuckle joints” in your hand, except they take a lot of pressure when we walk and run and are under continuous strain when wearing high heels.

Eventually, the plantar plate will wear out and start to thin, causing it to split, stretch and eventually tear. Sometimes, but not always, there will be some swelling under the ball of the foot extending towards the toes. Frequently, you will see buckling, hammering, and splaying of the toes. These conditions most often occur in the second toe but can also occur in other toes. People usually say it feels like they are “walking on the bones for the foot.”   

Sports or activities like dancing involve spending a lot of time on the ball of your foot. Some people have foot structures that predispose them to extreme pressure under the ball of the foot, such as a high arch, tight calf muscle, or other structural foot deformities, such as bunions. Weight, activity level, and either thin-soled or high-heeled footwear can overload the ball of your foot.

Diagnosing a plantar plate tear can often be challenging due to many other potential causes of pain in the ball of the foot, such as intermetatarsal bursitis, neuroma (pinching of the nerves), or thinning of the fat pad, which is the natural cushioning in the ball of the foot. X-rays or diagnostic ultrasound may be ordered to help evaluate the cause of the pain and the extent of the tear or degeneration.

Initial treatment may involve using anti-inflammatory medications, strapping the toe if it is buckling, padding to offload pressure from the ball of the foot, altered footwear, and activity modification. Cortisone infiltration into the joint in the early stages can be helpful for quick relief but not a long-term strategy and repeated injections can cause problems. As most plantar plate tears are due to degenerative changes, long-term management is primarily to offload pressure from the metatarsal heads to allow some repair and scar to form. However, there will always be a permanent weakness, and pain can quickly reoccur.

If the toes buckle and splay, this may get worse over time. Off-loading pressure is usually achieved by combining lower-heeled shoes with cushioned soles and a custom-made full-length orthotic device. This will usually stop the pain and help the toes from buckling further, but it will not correct the toes’ position.

Surgery is occasionally needed when the pain continues. If degenerative changes are present in a torn plantar plate, which is often the case, direct repair of the plantar plate is rarely successful. Stitching degenerative, thin, torn plantar plates is like trying to sew an old threadbare fabric together. The repair is weak and prone to fail once you load the repaired area again.

If the pain is not responding, an osteotomy to shorten the metatarsal bone may be performed to offload pressure from the plantar plate. If a hammer toe is present, this will usually also need to be corrected.

The key to understanding how to deal with plantar plate tears is to remember that, like osteoarthritis, we are dealing with one of the conditions that occur with your body’s response to wear and tear and aging. It usually requires ongoing management to keep you comfortable and prevent the injury from recurring.