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Sunday, March 8, 2020

Plantar Plate Big Toe Joint Injury: Email Advice

Nov 9th, 2019 I stubbed my big toe REALLY hard.  I heard crunching. Went to Podiatrist 2 days later, x-rays, was told I had an occlusal fracture on outside of big toe. Told to wear a stiff soled shoe, rest if possible. On December 23rd, I went back to Dr, another x-ray, no progress in healing (I wasn't the best at resting I admit), was then given a boot and told I could be weight-bearing as able.  Holidays, daughters home, etc, I did better at resting but started noticing other pains now, in ball of foot.  More swelling, purple when I didn't elevate it, tender.  Back to Dr. on Jan 23, x-ray, the fracture was definitely healing she said but maybe I should get an MRI to assess the soft tissue.  I should have said yes at that point but trying to save $.  
February 25 finally had MRI and told I have torn plantar plate under 1st mtp joint, subchondral marrow edema in same toe,  osteoporosis of several IP joints (which wasn't there before so I know this osteoporosis is injury-induced).  Dr. said let's give it 4-6 weeks of ABSOLUTELY ZERO weight-bearing (knee scooter, etc) and see if scar tissue starts to form.  She told me to ice 3x/day, elevate, NO heat.  (Today I found an article on your blog that talked about why I've at this stage may not be be best, but rather contrast baths. I did that and it felt intuitively much better than icing my already cold foot).  My question is:  Do you think there's a chance of scar tissue forming (binding the ligament together)? I don't want surgery if I can avoid it.  She said she's seen cases of that happening which is why she said we could wait another 4-6 weeks.....
Thank you

Dr. Blake’s response:
     . The way I look at this is that we want scar tissue to replace the tear, so the toe has to be taped for the next 6 months (not tightly to cut off the circulation) to limit the toe bending. You want to go through the knee scooter routine, and make sure at the end of that you are in an orthotic that off weights the area (probably with additional Dr. Jills Gel Dancer’s Pads on top), and shoes either bike shoes with embedded cleats or Hoka One One athletic shoes with rocker. I think it is crucial to walk width tape, shoe, and orthotic protection if you can keep the pain between 0-2. Some docs will go from scooter to boot and crutches to boot only to bike shoes or stiff hiking boots with orthotics in a progressive pattern. However, even though this is what I would do regardless, full thickness may not glue back and need surgical stitching of the ligament back down to the bone. You sort of know if we can not create the 0-2 pain level as we advance your function. The other problem is the fracture which may require bone stimulators or micro-fracture surgery, or simply resolve on its own. Your job is to take this information to your doctor, just be honest about the level of pain and your expectations at each point. I have seen patients successfully helped with conservative treatment and some requiring surgery. Since I try a lot of things, my patients if they need surgery know by 6 months from now. Remember anything you do now that protects the joint will be very helpful if you need surgery. I sure hope this helps. Rich 

Below first is my post on tears involving the 2nd toe joint, which is far more common than first joint, but still should give you more ideas. 

http://www.drblakeshealingsole.com/2015/01/capsulitisplantar-plate-injuries-of-2nd.html

Below is a good review article designed for podiatrists, but should give you some ideas also.

https://www.podiatrytoday.com/expert-insights-treating-plantar-plate-tears

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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.