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Tuesday, January 6, 2015

Capsulitis/Plantar Plate Injuries of the 2nd and 3rd Metatarsal Phalangeal Joint

Capsulitis/Plantar Plate Injury of the 2nd/3rd Metatarsal Phalangeal Joint
by Richard L. Blake, DPM
    Whereas the pain from metatarsalgia tends to be very generalized, capsulitis with or without plantar plate tears tends to be very localized to the bottom of one of the joints. Below is an example of an accommodative pad being applied to a pre-existing orthotic device in an attempt to float or off weight the area.

Accommodative Padding for  3rd Metatarsal Pain


    The top 10 initial treatments for capsulitis/plantar plate injuries are:
  1. Ice Pack for 15 minutes 3 times per day on the bottom of the foot, and change the last icing to contrast bathing as the symptoms improve each evening.
  2. Avoid barefoot and active push off or going up onto the ball of the foot.dreamstime_m_43905557.jpg
  3. Purchase Budin Splints, small longitudinal medial arch Hapads, and small metatarsal Hapads to experiment with immobilizing and off weighting the sore area.
  4. Mark the sore area with lipstick, transfer to the shoe padding, and try to accommodate the sore area. You can purchase 1/8th inch adhesive felt from Moore Medical to achieve this well.
  5. Analyze your shoes to see which types feel the best and stick with these. Stiffer the better is a general rule but may not apply to you.dreamstime_m_17464742.jpg
  6. Experiment with buddy taping the most involved toe to the toe next to it (not to the first toe however), or do a version of spica taping for those two toes to restrict dorsiflexion.
  7. Use activity modification principles to keep fit. Ride a bike with the pedal on the heel or arch. Use an elliptical without raising the heel off or using any elevation. Swim without pushing off the wall or walking in the shallow end of the pool.dreamstime_m_41305976.jpg
  8. Purchase an Anklizer removable boot if symptoms are not controlled in shoe gear.
  9. If the injury was traumatic, like with a fall, or if there is a marked amount of swelling, or an inability to bear weight, seek advice on getting an MRI and baseline x rays.
  10. If the toe involved has moved to a different position, it is the sign of a displaced fracture or torn ligament, and you should immediately seek advice of a podiatrist or orthopedist.

2nd MPJ Plantar Plate Tear: Email Advice

I'm a professional Rugby League player in England and have recently ruptured my Plantar Plate Ligament under my 2nd toe. The toe keeps coming out of joint and under the 2nd metatarsal head is very painful. I have 8-10 games left of the season and would like to play in the remaining matches. I can have a local anaesthetic for games but during the week when training i can't. I've tried all sorts of taping trying to keep the toe from coming out of joint and pulled down toward the floor but haven't found a suitable one that allows me to train properly. I wondered if you had any advice on taping techniques or some kind of splint that may help me get through the next few weeks. I'm having orthotics made to offload the pressure on the 2nd met head.

I hope you can help


Dr Blake's comment: Glad to try to help. Please try to find some Budin Splints. You should get the single, double and triple loop ones and experiment. For the Single Loop, you can put the loop over the 2nd only, or over the 2nd and 3rd toes combined. With the double loop, you can try 2nd and 3rd or 2nd and 4th. With the triple loop, you only have 2/3/4 possibility. You can also first try taping the toe down (I found a picture for the first, but you would do 2nd in a similar fashion) and then using the splint.  I also have found adding 1/4 inch adhesive felt over the top of the toe before you put your sock on can help push the toe down when you play (could not find a quick image of that). Many times you also have to put as much metatarsal arch under the 2nd and 3rd metatarsals as possible to lift up the metatarsals while pulling down the toes.I like the small longitudinal medial arch Hapads for this purpose. And then probably, if there is any more room in your shoe, to add a float to accommodate the 2nd metatarsal head at weight bearing.  Hope this makes sense. Rich

Hapad used for metatarsal support with an extra piece to the side of the sore area. When you use these Hapads, I use the right on the left and the left on the right. Go to for ordering.

Besides hapads for metatarsal support, accommodative padding of various forms and amounts can help off weight the metatarsal head.

Here a single loop budin splint is seen which can be put over the 2nd alone, or both the 2nd and 3rd toes combined. You can try tape first. Please check out

To prevent the toe splint from moving place a small piece of tape between the elastic band and the toe.

Even though this shows taping of the first toe, you can easily do the same for the 2nd. Use Kinesiotape, Rocktape or 3M Nexcare Waterproof tape.

Plantar Plate Tear of the 2nd MTP: Email Advice

Hi Dr Blake,
I'm desperate for advice. I'm 17 wks pregnant and after 10 mos of misdiagnosis and on/off pain, I was informally diagnosed with plantar plate tear of 2nd MT. My MD said since the pain has been present for 10 mos, the likelihood of it healing on its own is slim.  The joint is more lax dorsally than the uninvolved side and I have a mild hammer toe deformity. I started wearing a walking boot a week ago, and it provides almost complete pain relief.
I am a physical therapist. Really want to avoid surgery. Does this sound like it could repair itself? Does it sound like a grade 2 or 3 tear?  Will have to wait to get MRI until after pregnancy. Thank you!
Alice (name changed)

Dr Blake's comment:
  Sorry for your problem, and congratulations on the pregnancy. I have 2 wonderful unbelievable boys, and can not image life without them. You have a wonderful journey ahead. They will grow, but you also. Only an MRI will tell us grade 2 or 3, with grade 3 being a complete tear of the plantar plate. Unfortunately, due to your pregnancy, you must wait. The walking boot is now your gold standard. It has proven you can produce a pain free environment for healing. You must use it on and off for 3 months, unless you can find a shoe that gives you just as much pain relief. Consider looking into hike and bike cycling shoes with rigid soles, or hiking boots, or getting a Otto Bock carbon graphite shoe insole and see if it works in your athletic shoes.
But, whatever you are walking in, we must create a pain free environment over the next 3 months to try to create a great healing environment. During that time, you ice pack the area from the bottom 3 times a day for 15-20 minutes. This daily program reduces the inflammation, both the acute (daily), and the chronic (built up over the last 10 months). Begin to experiment with Budin splints to get the right tension and decide if you put over the 2nd toe only or over both the second and third toes. Sometimes, I will use the double Budin splint and place over the 2nd and 4th toes with the two loops. You will be wearing the Budin splint while you strengthen the area for 2 years. Some of my patients run marathons in these splints.

    As the pain calms down, and you get into more normal shoes, if the Budin splint is not enough protection, then you need to experiment with Hapad Longitudinal Medial Arch Pads or a custom foot orthotic device to perform that function. The most important thing to do right now, and for the next 3-4 years is daily Metatarsal Doming Exercises. This will strengthen the bottom muscles probably 3 times more than they were, but it is important not to curl the toes. It can take the next 1-2 months just developing the ability to keep the toes straight before you actually dome.


  1. Hi Blake,
    I think I have capsilitus. I have been treating it by wearing hoka one one shoes and not walking as much as possible. I have been getting better but my toes feel very squished in the hokas because of the narrow toe box. At the same time, those are the only shoes I can walk in without pain because of the squishiness and the rolled sole. I feel like I could get better faster if my toes were not squished, but I have to wear these shoes. Any other shoe recommendations?

  2. You can have a MRI when pregnant, just no gadolinium injection.

  3. Shortcomings of the hamstrings when contrasted with the quadriceps results in a more serious danger of damage, in light of the fact that the hamstrings back off the leg when running and kicking. treatment for a hamstring injury


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.