Tiem Bike Shoes with Embedded Cleats

For times when I want to immobilize the bend of the big toe joint for a while, but do not want the unevenness of a removable boot, I use bike shoes with embedded cleat. A patient came in with one the other day that I am using for a plantar fascial partial tear. I also use for sesamoid fractures, plantar plate tears, and hallux rigidus. 

Plantar View with Embedded Cleat

Top View of Tiem Bike Shoe

Cross Section Heel 
Area showing Partial Tear Plantar Fascia

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

New Video: Mechanical Treatment of Painful 2nd and 3rd Metatarsals and Toes

     I am happy to give you a new video on the experimentation that some of my patients go through in relieving the mechanical sources of their metatarsal and digital pains around the 2nd and 3rd toe area. Always remember that relieving pain can need all 3 sources addressed: mechanics, inflammation, and nerve related.

https://youtu.be/2dGq6DKbL4U

Partial Tear Plantar Plate: Email Advice

Hello Dr.Blake,

My name is Allison (name changed due to witness protection), I would really appreciate your time to answer me on my problem. I’ve been in a lot of pain and recently I had an MRI and was told I have a partial tear of the 2nd plantar plate. I’ve been advised to wear a boot for 2 months. Unfortunately I’m still in a lot of pain and don’t feel there’s any progress.
I found you online and I was hopping you might have any suggestions on what I should do to help heal and not be in so much pain. Doctors say there’s no successful surgery. Do you have any recommendation or suggestions?

I would really appreciate it, Thank You!

Dr. Blake's comment: First of all, thank you for placing this in the blogger contact area of the blog. It is nice to meet you. Secondly, surgery is a common treatment for this condition with great results, so that is important to know. The treatment conservatively, and even post surgery, is based on figuring out the mechanics to protect and off weight, controlling the inflammation, and calming down the very sensitive nerves. The removable boot is a go-to for 2-3 months, but only if the pain in the boot is 0-2 on a scale to 10. That way you know that you are calming down the tissue. Sometimes the boot only puts more weight on the metatarsals increasing the pain. If this is the case, the boot has to be modified to off weight the sore area, or abandoned for bike shoes with embedded cleats, or just really stiff shoes with no bend. 
     You have to work for several years with budin splints or taping of the joint while you ice daily. If there is any swelling, you want to do contrast bathing each evening and do more elevation than you are doing. Massaging the area initially painlessly with hand lotion for 2 minutes twice daily can desensitize the tissue relaxing the nerves. PTs and acupuncturists know how to relax the tissues. Here are some videos that may be helpful. Good luck! Rich



https://youtu.be/-v9IrSucQpE



https://youtu.be/928DwpwEaXE

Here is the concept of Budin Splint:
http://www.drblakeshealingsole.com/2010/04/pain-in-front-of-foot-possible-help.html

Here is a summary of plantar plate injury treatments:
http://www.drblakeshealingsole.com/2015/01/capsulitisplantar-plate-injuries-of-2nd.html

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, 

Plantar Plate Tear 2nd MTJ: Email Advice

Dear Dr. Blake,

I was wondering if you could help me with answering some of my questions.  Firstly, I'll describe my situation.  Right before Christmas last year I stopped running due to extreme pain I endured in my last two runs. I struggled even to walk so I altered my gait to take pressure off the top part of my right foot. I can say that after 5 months I can now walk without pain but that is because I walk without using the front part of my foot and no longer using winter boots as it's warmer.  Now I am using Merrell vibram normal shoes which I find comfortable and I can detect which part of my foot that I can use. My second toe on both feet are longer than my big toe.

I have had an xray of my foot and an MRI.  The results of my MRI are as follows:

Irregularities seen in 2. Mtp-joint with a few very small subchondrale cysts with basis of prime phalanx. Implied hydrops and small periarticulare deposits dorsally. Suspected a small avulsion cortical fragment from basis of phalanx. Also markedly edema lateroplantar along course of lateral part of the plantar fascia and lateral collateralligaments so could be the state after avulsion of the plantar fascia with a small cortical fragment from the base of prime phalanx. No enhanced intermetarsal bursa, no Morton's nevrom. Normal flexor and extended tendons. Unremarkable sesame bone complex plantate for caput of 1.metatars. 

In 2. MTP-joint suspected sequelae after avulsion of the plantar fascia with a small torn cortical fragment from basolateral part of prime phalanx, and some synovitt changes and beginning small degenerative deposits

Dr. Blake's Comment: Yes, from you image above, the lateral aspect of the plantar plate is torn causing the 2nd toe to drift medially (toward the 1st toe). 

I have attached a photo of my foot, where toe drifting of the 2nd toe is quite apparent (please excuse the look of my sticky taped toes).

I will be meeting with a surgeon in October in discuss options for surgery.

In the meantime i have been recommended to use Hoka arachi runners to avoid pain and the ability to walk normally. I have tried a pair on and when I try to walk as normally as I remember I do not appear to have pain.  I was wondering, if I should purchase these shoes? If I do, the main reason would be so that I could resume running until my surgery. I tape my toe regularly.  I do pronate and have used orthotics in the past but not since my injury. My main question here is, will I cause more damage to my toe if I start running in the hoka arcachi runners , more so than if I wait until the surgery and resume running again then? 

Dr. Blake's comment: As long as you maintain the 0-2 pain level, you are okay to run. The joint has arthritis starting (all the bone cysts and periarticular deposits), but hopefully the surgeon will clean that out at the time of surgery along with fixing the ligament. There are so many types of surgery for this, it is hard to know. 

     So many of my patients wait and wait on surgery, some preventing it, and some having it eventually. The pain is from the joint not lining up and the joint lining gets irritated. This is the same as the knee cap tracking slightly off line laterally, and the pain is unbearable to some (called "runner's knee"). Normally, we can get rid of the pain overtime with icing routinely, rocker bottom shoes to avoid toe bend (like Hoka), Budin splints (in your case a single loop is opened up and put over the 2nd and 3rd toes together, maybe even taping the 2nd and 3rd toes in buddy taping fashion, and using an insert like an orthotic to off weight the bottom of the 2nd joint with accommodative padding (I have many examples in my blog). I have so many patients that have the surgery after years of these treatments, not because they are in pain and disabled, but they just get tired of the daily process and they hope the surgery makes them better. Normally it does. Good luck. Rich

I really appreciate your advice on this matter.

Thank you,

Big Toe Joint Pain: MRI showing Plantar Plate Involvement

This is one of my blog patients (and yes, that is what I call you in my brain as I compartmentalize things). He has been suffering with big toe joint pain, presumably sesamoid, but probably more plantar plate tear. The arrow points to part of the plantar plate in front of the sesamoids by the toes. Some calm down by themselves with sesamoid off weighting, and limited push off for a while. Some remain chronically sore and need surgery to fix the instability created by the tear. Typically, you know what a surgeon will tell you. Read all you can about sesamoid management--off weight the big toe joint, limit the dorsiflexion of the joint, calm the inflammation down (all the white stuff in the image), create a pain free environment. Also, look at my reference on plantar plate testing.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560019/



Turf Toe Stable or Unstable: Surgery or No Surgery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560019/


I just reviewed an MRI and x-rays of a patient with chronic sesamoid injury and there definitely was plantar plate involvement. This is a great article documenting an unstable plantar plate with a 2mm forward position of the non injured sesamoids. The x-rays should be taken in a position where the big toe is bent upwards, called a stress x-ray. 

Arrow under the big toe joint shows a disrupted plantar ligament (plantar plate) with intense inflammation.

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 plié 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

Hallux Limitus Discussion: Dancer's Padding or Reverse Morton's Extensions

​Dear Dr. Blake,

     I am a senior podiatry student. I was just reading one of your blog posts (Sesamoid Fractures: Advice when not healing well) and I have a couple of questions I was hoping you could clarify for me.

     My questions actually have to do more with hallux limitus. I have been trying to understand the difference between offloading the 1st MPJ with a dancer's pad for conditions such as sesamoiditis versus using a reverse mortons extension for a hallux limitus. Essentially they seem to be the same pad? But how could one be offloading and relieving pressure while the other one is increasing plantarflexion of the 1st MPJ (and I assume that would be increasing pressure) to decrease the elevatus?

Dr Blake's comment: Dancer's pads and Reverse Morton's Extensions are one and the same. I would rather give credit to the French who in the 1770s while studying their ballet dancers came up with this unique pad for big toe joint pain. It was the time of the French Revolution, but also the time of this unique pad that was not placed over the sore area, but designed to transfer weight. A truly revolutionary idea!! A dancer's pad should transfer weight from the first metatarsal to the second through 5th metatarsals at push off. When this works, normal push off occurs with the first metatarsal being free to plantarflex for an active push off. When there is too much weight on the first metatarsal (say from over pronation of the foot), then functional jamming and pain can occur as the first metatarsal tries to plantarflex at push off but is being restricted. So, at push off you want normal plantarflexion of the first metatarsal, with normal to slightly less than normal plantar pressures. This can help a pain syndrome produced by that jamming force. And, push off is only one third of stance. Dancer's pads do eliminate a lot of pressure on the first metatarsal during the contact and midstance phases. So, all 3 phases of stance have less pressure on the first metatarsal with a dancer's pad, and active push off should be less restricted and therefore more powerful. Now, a structural met primus elevatus is best helped by a Morton's Extension. It brings the ground up to the first metatarsal and allows it to function normally. A functional met primus elevatus, caused by over pronation, is only elevated by the pronation jamming it upward. It needs arch support to decelerate pronation, shifting the weight in midstance to the middle of the foot, with a dancer's pad to free up the jammed big toe joint. Besides Dr Root, Dr Langer first discussed this concept in the 1980s. Drs Wernick, Langer and Dannenberg introduced the kinetic wedge with first ray cut outs to free up the first metatarsal to achieve wonderful push off. The basic concept was that some arch support, and some first ray freedom, would help the first ray push off. This is achieved in various orthotic modifications. I love adequate over pronation correction from the orthotic device, along with some dancer's pad to give extra freedom. Dancer's pads have been crucial in pain syndromes, and less necessary when there is no pain (although always an option to add). 

Also, If someone has a hallux limitus and a plantar plate tear of the second, would you recommend doing a spica taping to the first and the second toe simultaneously? Your instructional video on Youtube for this is excellent. My mom actually has this issue and I have been trying to research different taping methods since she does not want surgery. I bought her a morton's extension innersole but she also doesn't wear sneakers very often as she is a dancer. She is hypermobile so perhaps using a reverse mortons extension may help the joint align. However, I am worried to add pressure to the sesamoids because she also states she has pain there (hence my confusion on padding). I have included a photo of her foot and x-ray just in case my rambling doesn't make sense.

Dr Blake's comment: Even though you are only a student, you are asking great critical questions. The main treatment for a plantar plate tear is a Budin splint or spica tape to the 2nd/3rd toes (typically buddy tape to share the pressure). Look at the Hapad products. Start with an Extra-Small Longitudinal Medial Arch for the Hallux Limitus to shift weight more central. Add a Budin splint for the 2nd/3rd toes (Single loop opened up for both toes). You can trim the Budin splint plantar padding as much as you like, and you can even add an extra small metatarsal pad to the splint. 

Dr Blake's comment: The xrays point to that long first metatarsal that gets jammed at push off. This is typically initially a functional jamming (functional hallux limitus), which can become osteoarthritis (structural limitus or rigidus). Since you can not load the second met head, you have to support the arch to transfer weight from first to central. 

 She also has a strange lump on the medial 2nd digit. She was told by a podiatrist that it was just bursitis but I am not convinced since it is a hard lump- feels almost like an extension of the medial condyle of the prox phalynx...the x-ray just looks like a bit of increased density in the soft tissue. Have you ever seen something like that before?

Dr Blake's comment: With plantar plate tears, the second toe can start to deviate to the the loss of plantar ligament stability. Here you see the second toe proximal phalanx deviating towards the first toe. She may need that fixed surgically some day. And, today definitely needs to live with a Single loop Budin splint with the loop opened up enough to cover both the second and third toes. I sure hope this helps her and good luck with your career. Rich

I am going to have her start doing the joint mobilization that you recommend in your other blog post.

So sorry for the long e-mail. I really appreciate you taking the time to read this. I am looking forward to your response. 

Best Regards,

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.
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.
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.
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

Hi

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

regards

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 www.hapad.com 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 www.amazon.com

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.

2nd MPJ Plantar Plate Tear: Email Advice

Hi
I'm a professional Rugby League player in England and have recently ruptured my Planter 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

regards

Dr Blake's comment: Glad to try to help. Please try to 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 www.hapad.com 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 tape first. Please check out www.amazon.com

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

Even though this shows 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 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 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. 

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. 

     Good luck and congratulations. Rich