Plantar Plate Tears
The plantar plate is a ligamentous structure on the bottom of the foot which connects to each toe. It is comprised of many soft tissue capsular, tendinous, and fascial insertions which serve to pull the toe down toward the floor. The plantar plate often tears at its insertion on the base of the toe and sometimes when the plantar plate tears, the toe will begin to deviate out of alignment and may start to raise off the floor. Patients often complain at pain at the base of the toe and the toe appearing to be out of alignment with the other toes.
A toe with a plantar plate tear will usually hurt over the ball of the foot at the base of the affected toe. The second toe is most commonly affected. The toe will begin to deviate toward or away from the big toe. It will also sometimes raise off the floor to create a hammertoe.
To fix this problem, surgeons have historically transferred tendons from the bottom of the toe to the top of the toe to pull the toe back down to the floor. The 'flexor to extensor tendon transfer' is still considered a very good operation and is still used quite commonly today. Another alternative to the flexor-extensor tendon transfer is to directly repair the plantar plate. Plantar plate repair has evolved significantly over the past decade and now surgeons have a more complete understanding of plantar plate tears and better surgical tools to access and repair these tears. Sometimes the plantar plate tear cannot be repaired or the repair may be performed in conjunction with a flexor-extensor tendon transfer. The repair is performed with sutures to re-approximate or advance the plantar plate back to the base of the toe (See video below). Part of the operation involves shortening the toe a few millimeters with a 'Weil Osteotomy.' Shortening the toe allows the surgeon to gain access to the plantar plate and also decreases tension and forefoot pressure post-operatively. The surgery is meant to relieve pain at the bottom of the forefoot and to re-align the toe and bring the toe back down toward the floor. Often times multiple toes are done at the same surgical setting. Sometimes additional procedures are added to the plantar plate repair to help accomplish re-alignment including: Weil osteotomies, flexor-extensor tendon transfers, extensor tendon releases, capsuloplasty, neuroma excision, and hammer or mallet toe correction.
Following surgery, careful postoperative care is needed in order to keep the toe in proper alignment while healing occurs. Usually patients do not need to spend the night in the hospital after a plantar plate surgery unless other procedures are done simultaneously. We will need to see you back in the office about one week after surgery. Frequent office visits are necessary to inspect the incisions and to splint the toes in a correct position. You will be able to weight bear on you heel the first week after surgery after your nerve block wears off, but to help insure a good outcome we will ask you to walk flat footed for 6 weeks without using your toes to push off. It is not usually necessary to wear a cast as a postoperative surgical shoe will suffice with toe taping for about 6 weeks. Also beginning around the second or third week we will have you begin doing stretching and exercises with you toes. This includes doing toe crunches which is the the motion mimicked by performing a task such as picking up a marble with your toes. Transitioning back into a regular shoe usually occurs around 6 weeks after surgery and at this point you can begin walking more normally and less flat-footed. Impact activities such as jogging usually take at least 12 weeks. Time off from work depends on the type of job but prepare to take off at least one week because elevation of the surgical extremity above the heart is very important for the first few days.