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Sunday, January 6, 2019

Chronic Plantar Plate Injury: Email Advice



Hi Dr. Blake,

I got your email from your blog and I am hoping you can spare a minute to offer me some advice. I have read online that you have been very helpful to people suffering from this condition and I would greatly appreciate your advice.  I am a 31 year old teacher who lives in Canada and I have been suffering from pain around the second mtp joint in my right foot for about 10 years, ever since a single traumatic misstep while running barefoot. At the time of my original injury I was put in an air boot and a bone scan rules out stress fracture or necrosis etc. But the culprit for the continued pain was not found.
Dr. Blake's comment: At least bone was ruled out, could be soft tissue ligaments or nerve pain.
 Other the next 10 years the pain persisted most notably in and above the second mtp joint, while underneath the joint remained tender, it wasn’t as sore as the joint itself. I had about 5 cortisone injections into the area over the years with little improvement.
Dr. Blake's comment: Unless the doctor is injecting Morton's neuroma pain, have them limit it to short acting cortisone. Long acting cortisone can possibly hurt the ligaments.
 Finally, a podiatrist diagnosed the injury as plantar plate dysfunction about 2 years ago (ultrasound confirmed this (fluid under joint) though a recent mri showed no abnormalities of the plantar plate) and I was gaining some relief through taping and custom orthotics (though the pain in the second mtp joint was never fully alleviated, the pain under my foot had improved a lot after wearing insoles for the last year). I was also using diclo cream. My toe slightly migrated away from the big toe but it is not very noticeable.
Dr. Blake's comment: The MRI and ultrasound should have got the same results. Interesting, what was the Lachman test like?

Recently, Because I was still having pain, and a joint drawer test (same as the Lachman test) indicates my second mtp was not stable, I was offered a second mtp osteotomy by an orthopedist surgeon but he thought I should try prp beforehand, just to see if the joint would respond. The doctor who administered the prp injected it into the top of my second mtp and also directly into the plantar plate, this is where my current dismay began.
Dr. Blake's comment: The surgeon must have been going to due something else to repair the ligament.

Since the prp injection 3 weeks ago, my plantar plate feels as sore as it did when I was initially injured 10 years ago. Experiencing this renewed pain on the bottom of my foot makes me realize how much it had improved with taping and orthotics over the last year and how all of my pain was actually coming from the joint itself (and notably felt on the top of the foot rather than the bottom). Now I am worried that the trauma of the prp needle and the injection of the fluid may have made my injury on the bottom of my foot worse. It has been 3 weeks and the area can still not bare weight .

Can you offer any advice regarding my current predicament ? Do you think prp could cause more damage ? Should I expect the prp to take longer to heal due to the  rigid nature of the plantar plate ligament and it’s lack of blood supply? . Should I treat the site as a new rupture (and try and immobilize for 6-8 weeks) or follow prp post-procedure guidelines and keep using the area as normal in a stiff soles shoe? Also, if/when this pain on the bottom of my foot is alleviated, should I consider the second mtp osteotomy to address the original issue of second mtp joint pain ?

Thank you very much for your time - I hope to hear from you!
Dr. Blake's comment: The PRP from the bottom was hitting all the nerves in the area and is very painful in general. Yes, if you can not bear wear, go into a removable boot for the next month or so, and ice now. I know you are not supposed to ice with PRP as it is trying to make a new injury and mount an immune response. Get this calmed down, and you hopefully will have found this helpful to you. In one month, if you are not much better, I would seek an MRI to see what the tissue looks like. Too early to talk about surgery. I hope this helps some. Rich


The patient then responded:
Thank you for getting back to me so quickly! I will begin icing my plantar plate and get into a boot for the next month. Do you think the pain is likely causes by inflammation or upset nerves rather than additional tears in the ligament due to the needle? Dr. Blake's comment: Yes.
I realize a needle point is a fairly small implement so I’m scratching my head as to how much pain I am in 3 weeks later. I spoke to my brother-in-law who is a physiatrist and he says it is rather unlikely a needle could do any real damage.... I have a follow up with the orthopaedic surgeon in two days so I’m wondering if you have any advice on things to mention to or ask him ? Dr. Blake's comment: Yes, talk to him about another MRI in a few months, PT to calm the joint down, ask him if he does just ligament repair of the joint (not osteotomy). I guess if the second metatarsal is very long, an osteotomy should be in the discussion, but many surgeons just sew the ligament  where it is torn and place the patient on Budin Splints for a year to hold the toe from moving. You can also not fix the tear, but sew the joint on top tight for the least rehabilitation. I had a podiatry surgeon tell me they did that on some professional basketball players to get them back faster. You can talk about a arthrogram where they inject dye into the joint to see if there still is a tear. If the dye leaks from the joint, the tear is still present. Ask his or her advice on calming the nerves down quicker. Should you be using topicals like Neuro Eze or Lidoderm patches. They have compounding medications for nerves by RX. Does he/she believe it is nerves or inflammation or both. What about a 6-8 day course of oral cortisone to calm it down?
 As I know that it will be too early to make a decision on a procedure due to the post-prp pain but I figure I’ll keep the appointment so he can at least take a look at the area and I can bring him up to speed. Also, I purchased a portable TENS machine and I am wondering if you think this would be suitable to use on the area ? Dr. Blake's comment: If you know how to use it. You may need a PT to instruct you the best way, especially how low to start so you do not irritate things more.

Thanks again for your help! It seems like it is nearly impossible to find information on this topic online so I truly appreciate your time and effort .

Best, 

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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.