Phil White Lateral view 2 nd MTP joint Reference httpwwwradsourceusclinic0912 plantar plate PP proper collateral ligament PCL accessory collateral ligament ACL fibrous capsule C and deep transverse metatarsal ligament DTML Additional structures depicted include the ID: 920111
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Slide1
Plantar plate defects: what a pain.
Phil White
Slide2Lateral view 2
nd
MTP joint
Reference http://www.radsource.us/clinic/0912
Slide3plantar plate (PP), proper collateral ligament (PCL), accessory collateral ligament (ACL), fibrous capsule (C), and deep transverse metatarsal ligament (DTML). Additional structures depicted include the
intermetatarsal
bursae
(B), dorsal
interosseous
tendon (D), extensor
digitorum
brevis
(EDB), extensor
digitorum
longus
(EDL), extensor expansion (EE), Flexor
digitorum
brevis
(FDB), flexor
digitorum
longus
(FDL), neurovascular bundle (NVB),
lumbrical
tendon (L), plantar
interosseous
tendon (P), superficial transverse metatarsal ligament (STML). Reference http://www.radsource.us/clinic/0912
Slide4Slide5Clinical
Focal pain under MTP joint (rather than interspace)
Not numbness or shooting painO/E Splayed/ rotated toe+ve draw test > 2mmSwelling/redness
Slide6Mechanism of damage
Chronic
microtraumaHallux valgusLong 2nd rayFootwear- High heeled shoes, narrow toe boxAcute stub toe injuryAthletes
? Secondary damage from synovitis? Steroid injections
Slide7Imaging
Radiographs
May be suggestiveMRIVery high quality imaging essentialUSDifficult, time consumingMisdiagnosis common
Slide8Radiologic Clinics of North America
Volume 46, Issue 6
, November 2008, Pages 1061–1078
Coronal (transverse)
Sagittal (longitudinal)
Normal PP on MRI
Slide9Normal MTPJ U/S
Dorsum- no MTPJ effusion/
synovitisDynamic stress test- examine joint stabilityPlantar- check plantar plate (dynamic, LS), flexor tendons, interspaces.PP more difficult to assess on TS scanningCorrelate with symptoms/ tendernessTakes about 6
mins per foot to do.
Slide10Radiologic Clinics of North America
Volume 46, Issue 6
, November 2008, Pages 1061–1078Normal US plantar plate
LS
Prox
phalanx
MT head
Slide11What are plantar plate defects?
A split or cleft
Progressing to a tearWhich may extend into the collateral ligaments“degenerative change” in the plantar plate without a tearResulting in instability, pain etc.
Slide12Suggestive plain film findings
Help to exclude other causes
Non specific! Any combination of-Hallux valgus/ OA 1st MTPLong 2nd MT with cortical thickening
Bone reaction base prox phalanx/ osteophytesSplaying 2nd and 3rd toes
Slide13Slide14MRI PP tear
Usually near distal insertion, base of toe
Central part of the PP → lateral/medialMay show effusion in MTP joint and oedema around the jointBut- scans often not of diagnostic qualityNormal recess at insertion can look like a small PP tear
Slide15Slide16Slide17Slide18Slide19Slide20Slide21Slide22Slide23Slide24Slide25Slide26Slide27Slide28US PP tear
Dorsal aspect-
Dorsal fluid/ synovial thickeningInstability on dynamic stress scanPlantar aspect- (Dynamic scanning, MTPJ)Plate defect (hypoechoic, dip of FL tendon)
Hyperechoic triangle base prox phalanxFlexor tendinitis and fat pad changes Look for Intermetatarsal bursitis, etc
Slide29Proximal phalanx
4
th
MT headLongitudinal
Slide30LS
Slide31LS
Slide32LS
TS
Slide33MT head
MT neck
Slide34LS dorsum
TS plantar
Proximal phalanx
2
nd
MT
Slide35Prevalence of PP tears*
in
asymptomatic feet-US 75/160 plates; MRI 56/160 platesAge and PP tears (patients + volunteers)-<30 yrs: 42% 30-45
yrs: 56%45-60 yrs: 81%>60 yrs: 93%
*Gregg at al
Eur
Radiol
2006-
sonographic
and MR evaluation of the plantar plate
Slide36Site and frequency of tears*
78% of all 2
nd MTPJ PPs had defects; 73% 3rd and 4th; 46% 5th
*Gregg at al Eur Radiol 2006-
sonographic
and MR evaluation of the plantar plate
Slide37Significance of PP defects*
Moderate correlation between pain and presence of a tear
Fair degree of correlation between pain and length of tear (<1, 1-2, >2mm)Marked correlation with age“plantar plate tears may be significant if they result in weakening of the joint capsule, producing instability, synovitis...”
*Gregg at al Eur Radiol 2006- sonographic and MR evaluation of plantar plate
Slide38Differential diagnosis
Morton’s neuroma
Intermetatarsal bursitisFlexor tendinitisOA MTPJsFreiburg’sDistal MT stress fractureAnd more
Slide39Slide40Treatment
Team approach with Orthopaedic foot surgeons, podiatrist/
physio and orthotistIf unresponsive to footwear advice, orthoticsMainly MTP joint synovitis -> image guided MTP joint steroid (expect recurrent pain after 6/12)
Mainly intermetatarsal bursitis -> US guided injection (expect recurrent pain after 6/12)Recurrent/ young patient/ trauma history- ? Repair. ? When
Slide41Conclusions
Common cause of pain, instability, toe deformity
Imaging is difficult, the role is uncertain, most MRIs and US scans are inadequate for diagnosisAsymptomatic defects are commonMost Radiologists are unaware of the condition
Slide42References
Klein et al, Foot and Ankle Specialist 2013 MSK US for preoperative imaging of the plantar plate
Gregg, Radiol Clinics of North America, November 2008, Pages 1061–1078. MRI and US of metatarsalgia