Plantar plate tear vs capsulitis
Every so often I thumb back through old journals and pick up a few pearls that'll be pertinent to either patients who I am currently treating or cases that I've seen over the years. I was reading an article in The Journal of Foot and Ankle Surgery dated Sept/Oct 2012. The article by Sung, et. al was called Diagnosis of Plantar Plate Tears by Magnetic Resonance Imaging with Reference to Intraoperative Findings. What the article was attempting to do was to correlate MRI findings of plantar plate tears with surgical findings. Their outcomes in the article definitively stated that the accuracy and specificity of MRI findings and how they related to surgical findings were greater than 95%. Based on this knowledge, the authors advocated surgical correction for MRI confirmed plantar plate tears.
Every practice is going to be a bit different in their approach to specific clinical conditions. And in many cases, decision making in part is driven by the literature. Decision making in surgery is driven by a) where you trained, b) with experience, what you find works best in your hands and c) current findings in peer-reviewed literature. As a patient, you need to understand that for a specific condition, like a plantar plate tear, you may get a number of different opinions based upon training, experience, and literature. Knowing this, how does a patient decide what they should do to treat a problem?
As a clinician and surgeon who's been active for the past 30 years, I have a little bit different take on plantar plate tears. I'm much less aggressive with surgical treatment of plantar plate tears knowing that the symptoms of many will subside over time with conservative care. The question I often ask myself is whether the forefoot problem that I'm seeing is a case of forefoot capsulitis or is it actually a plantar plate tear. Granted, I do believe the authors are correct in using an MRI to reach their conclusion, but does every patient with forefoot pain need an MRI? Or is there a simpler and less costly way in which to proceed when treating plantar forefoot pain?
In cases where the toe is deviated and pain does not resolve with conservative care, an MRI is indeed indicated to rule out a plantar plate tear. But in cases of plantar forefoot pain with no deviation of the digit (hammer toe or transverse plane deviation), I'll initiate care with the use of a metatarsal pad. Metatarsal pads can also be combined with a spring plate. The vast majority of these cases of plantar forefoot pain resolve with the use of these off-loading methods.
The authors of this article did an excellent job in correlating clinical testing and surgical results, but a follow-up article describing the percentage of plantar plate tears as a differential in forefoot pain would be helpful to clinicians and their patients.
Jeffrey A. Oster, DPM