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Thursday, February 2, 2017

Possible 1st Plantar Plate Tear

Hi Dr. Blake,
First of all, thank you so much for all of your hard work on your blog and for taking the time to answer these types of emails.

My story is a frustrating one so I'll try to start from the beginning and provide as much detail as possible.
I'm a tap dancer who rehearses weekly for about 2 hours twice a week. I've been tap dancing since I was 2 years old and it is truly my passion. I've never been injured as a dancer.

This past November I attended a tap workshop in which I was dancing pretty much non stop for 6 hours straight for 2 consecutive days. By the last class of the second day I had some pain in the ball of my foot but chalked that up to normal for the amount of pounding my feet had taken, and didn't think much of it. The next day something in my left foot didn't feel right. I wouldn't say it hurt but it felt somewhat unstable. I still didn't think too much of it until the next day it down right hurt when I walked on it a certain way. I could still walk but I was limping a bit. There was also some swelling. I called and made an appointment with a sports medicine physician in my area who deals a lot with foot injuries. I also shifted to wearing only birkenstocks and sneakers at this point.

In my initial appointment, the doctor did x rays which showed no fracture and had me go up on my toes which at this point had become impossible for me. I instantly felt intense pain with this action and a grinding or buckling sensation in the big toe joint. He prodded around the bottom of my joint and ended up diagnosing me with sesamoiditis and tendinitis of the FHL. He put me in a walking boot for 4 weeks and gave me oral steroids to reduce inflammation and told me to start physical therapy when the swelling went down. I followed these instructions and did start to have improvement. My foot felt 90% better by Thanksgiving and I was feeling optimistic. At this point he had told me I could start weaning out of the boot.

I think I became overzealous and decided to spend the first weekend of December bringing my winter clothes downstairs from storage. I spent the whole day going up and down stairs in my Birks and not the boot. By the end of the day I knew something was wrong as my foot had swollen again so I put myself back in the boot and wore it throughout the holidays  and scheduled a follow up with my doctor at the first of January.

At this point he recommended I wear the boot but try to wean out of it as I'd been in it for almost 4 weeks and go back for more physical therapy. I did this and the swelling did go down but I still could not walk normally. I persisted with physical therapy for 3 weeks and was able to go up on my toes again but still had issues with the toe off phase of normal walking. In PT I was able to do 3 sets of 10 reps of heel raises on my injured foot at a time, but when I'd try to walk normally I'd feel a twinge of pain in the ball of my foot between my big toe and second toe.
Dr Blake's comment: Definitely some good overall improvement. 

At home I was doing stretches for my calf muscles and hamstrings. I decided to try some stretches from ballet and did a pliƩ in second position. Upon so doing I felt something pop between my big and second toe and later pain, and then it was swollen again. I scheduled another appointment with my doctor who continued to say this was sesamoiditis, wanted me to buy a pair of custom orthotics that would run me $260 because my insurance wouldn't cover them and wanted me to buy steel plates for my shoes. He refused to do an MRI and gave me no further instructions and told me not to use the boot anymore.

In my frustation I decided to seek a second opinion - this time, from a very highly regarded orthopedic surgeon specializing in the foot and ankle. He promptly ordered an MRI as I heard that should have been done a long time ago for proper diagnosis. He told me to continue wearing the boot until further notice. His PA called me with the results today and told me that the MRI showed significant damage to the plantar plate and at this time he was thinking surgery was going to be the best option.

 I have the MRIs on a disc and could send them to you for review. My question is, in your opinion, am I past the point of conservative treatment being helpful? Is surgery really my only option. As a dancer it has pained me to be out for this long and I am aching to be dancing, or even doing moderate physical activity of any type. Any insights or recommendations would be so appreciated.
Thanks,
Dr Blake's comment: Yes, send the MRI to Dr Rich Blake 900 Hyde Street San Francisco California, 94109. Plantar plate tears of the 1st or 2nd joints are uncommon, and can take a long time to heal, if they do. Some patients prefer the conservative route and do well, while some go straight to surgery to a faster rehabilitation (but no surgery is without potential complications). Let me confirm the diagnosis. You should be back in the removable boot for 3 months. I think your initial injury was healed or almost healed, and the plie caused possibly a new injury. Or you changed a partial and healing tear, to a complete tear. Anyways, back into the boot. Let's see if the MRI makes everything clear or muddy, and go from there. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.