Plantar plate tears are not to be messed around with. I hate repairing them! Don't run until you get a good diagnosis.

Having said that, a plantar plate "tear" of the great toe joint is quite rare and much more common of the 2nd MPJ. Sub 1st MPJ pain usually sesamoid related.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

thanks Dr. Roof. this is first joint from the fall and doc said sesamoids are not involved (from standing X-ray) i guess MRI will show that.
is it common for the pain to go away and being able to run a marathon and then come back? how about biking and swimming?
thank a ton.

No, that would not be common if "torn" from the original fall, then to be able to run a marathon, then hurt again.

Swimming certainly fine (just don't push off the wall with that foot). Some easy MTB probably OK, but hold off anything that really loads the forefoot otherwise (running for sure, but even lots of walking, dress shoes, hills, etc.)

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Will report back after i get the MRI. Not sure what best case scenario is regarding results - no torn ligament????
thanks Dr. Roof

I had a plantar plate tear of the 2nd MPJ about four years ago. Started in late-2011 or early-2012 and plagued me all of 2012. Did the Texas 70.3 and Syracuse 70.3 and then the pain started to be a bit too much so went and saw a doc. Was told rest, ice, NSAIDs, and all that for a period of 4-6 months... and no running. The no running part was interesting because I had IMAZ in November 2012. Yeah, I did IMAZ on zero run training. Saw doc for follow up just before and saw him again in January 2013. The problem persisted. I didn't want surgery to be an option.

In addition to the plantar plate issue (or partly because of it), I was having calf and achilles problems as well. Then I read Dan Empfield's "Mad Calf Disease" article about Hokas and decided to purchase a pair. Hokas solved my problem and have been trouble free ever since. Also much cheaper and less painful than several more orthopedic surgeon visits and/or surgery.

Dr. Roof can correct me if I'm wrong but in some research on the subject the choice of shoes can be a huge factor in plantar plate problems. Some shoes add increased pressure on the forefoot, and this can be a contributing factor to plantar plate problems. So something like Newtons or zero drop shoes or racing flats can cause issues with certain people. Shoes like Hokas with the rocker can take pressure off the forefoot. Not saying to go out and buy a pair of Hokas as some magic elixir but it might help as it did for me.

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Favorite Gear: Dimond | Cadex | Desoto Sport | Hoka One One

I had the great experience of tearing my plantar during college. I could not walk on it without crying and ended up being out in a boot for about 8 weeks then back to doing walk-jog to get back into the swing of things. Definitely go for the MRI because as many have said before this is something that you need to figure out and address. Good Luck.

I had a partial tear in my 3rd met in late March, which I believe was caused from stepping on a stone during a trail run about 4 weeks out from a marathon. Bailed at mile 15 on race day, once I realized my goal time wasn't gonna happen. The pain wasn't excruciating like many others experience, but I could feel it with every step, and when I pulled the toe upwards it was definitely a noticeable pain.

I didn't run a step from May until October, but I did ride all summer without any pain, and did some swimming as well (no flip turns as Doc Roof says). It took 3 months before I stopped feeling it on every footstep, although this was probably because I didn't wear a cast or boot (since I wasn't in a ton of pain, my doc and I decided to be conservative with treatment). During that time I got rid of my old running shoes, and I messed with metatarsal pads but didn't find they really did much for my pain. I did tape it every day for about 6 weeks (get the flexible tape that moves a little....Tensoplast is what I used). I started running about 8 weeks ago, and no issues so far. Hopefully it's gone, but I'll be playing it safe as I ramp up train speed and distance.

This was the first "real" running injury I've had in almost 10 years that I couldn't run through, and it was definitely a struggle to get it diagnosed properly. It was also difficult to remain optimistic about eventually returning to running, but if you live in the northern hemisphere, this is the offseason so you have time to let it heal properly before building for the spring. Listen to your doc and follow the rehab protocol. Probably the best advice I've heard in regards to this injury is "wait until you have no pain...and then add 4 weeks before you start running again." Best of luck!

I would get the MRI

I tore the plantar plate on 2nd mpj and ran on it for 5 years using modified orthodics. I had to have 2 surgeries to get everything fixed. It's all fine now, but I wish I would have gotten everything done sooner. Get the MRI and figure out next steps

Absolutely going to get the MRI; scheduled it for Friday. I am hoping that it is just tendonitis as opposed to tear or sprain.
The thing that blows my mind is that after the original trip and fall, the pain went away and was able to run the marathon pain free and the pain came back a week ago. Makes no sense to me. Guess it doesn't matter now.

I did do a computrainer class this morning. Not sure if that is too much forefoot pressure.

Dr. Roof, i have a boot at home (from previous achilles issue), should i wear it?

thanks everyone for their replies

Won't hurt to wear it for a few days until you get more info from your MRI if you happen to have one. A bit of "forced rest" always good

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

hope to hear back on your MRI report.

got the MRI report back:



my impression is that it's a bone bruise. no tears and sprains. some degenerative stuff; probably usual for 60 year old. Dr. Roof - what do you think? good news or bad? don't see doc for a few more weeks. been wearing the boot and not running. (BTW neuroma thing is a surprise as i have no symptoms).
thanks. appreciate any thoughts.

sorry if you can't open the report. Here it is:
"there is a moderate diffuse bone marrow edema in the first metatarsal head, out of proportion to mild to moderate overlying cartilage loss, concerning for moderate bone bruise. no evidence of significant sprain or tear in the plantar plate and sesamoid-phalangeal ligaments. Moderate degeneration is noted in the collateral ligaments of the first metatarophalangeal joint. Mild joint effusion and synovitis in the first metatarsopalangeal joint. The visualized extensor and flexor tendons are intact. there is a 7x4 mm morton's neuroma in the third plantar interdigital webspace. the intrinsic musculature is intact.
IMPRESSION:
1. Moderate bone bruise in the first metatarsal head and neck.
2. Mild to moderate cartilage loss with small dorsal spur in the first metatarsal head. Mild joint effusion and synovitis in the first metatarsophalangeal joint. No evidence of significant tear or strain in the plantar plate or sesamoid-phalangeal ligaments.
3. Third interdigital webspace Morton's neuroma".

Need to correlate MRI findings with clinical symptoms/findings. It appears your MRI findings should have also shown on plain film X-ray though (your great toe joint arthritis for example). Don't worry about the incidental finding of the "neuroma". Radiologist just reading what he/she sees.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

thanks Dr. Roof. to the best of my knowledge, the X-ray was not remarkable for anything. the doctor never mentioned anything remarkable. i see him 12/28.
in the interim, should i try running/biking? it feels better as i have been in boot and haven't tested it.

thanks.

That is why it feels better ;-)

Do whatever your hands on treating physician said you can do at this point. Not sure why you aren't seeing him sooner after your MRI (probably busy around the holidays - I sure am, or time off, etc.) No one has all the pieces though but him

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

ha. no openings until then. i know ridiculous. any way, after some sleuthing on google i read that a bone bruise is not what we think it is; it is actually a fracturing of the inner layer of bone. that doesn't sound so good to me!! not quite a stress fracture nonetheless something i guess i have to wear a boot for. not happy especially since this was a trip and fall. so i stay in boot until at least 12/28. i might try some swimming w/o pushing off the wall. not sure about computrainer.

thanks for your help dr. roof. i was kind of happy when i first read "bone bruise". bah hum bug.

Saw doc today Dr. Roof. He didn't seem concerned about the bone bruise and mostly concerned with the cartilage loss. he said it was arthritis, bone on bone. He said i should wear the carbon plate he gave me (found it uncomfortable so didn't wear it), get orthotics that keeps the big toe from flexing and to buy more rigid sneakers. i have been wearing adidas supernovas which are very flexible.

he didn't seem too alarmed that my running career was over. he also said he could give me a topical arthritis cream to put on the big toe. I seem much more scared than him. Arthritis is a running career killer, no? I think bone on bone and i can't imagine being able to run pain free again. I have not run in three weeks but have done computrainer classes. The biking seems to flare it up (pedal is right in ball of foot).

Dr. Roof - could you please give me your opinions. my MRI report is in a post from a week ago.
Thanks a lot.

My 2 cents; I am sure rroof will chime in with sage advice as well.

Use the carbon insoles in everyday shoes; a good orthotist could put an overlay on them to create better contact and they will be much more comfortable. Alternatively, if it is just the first ray than an rigid extension for just the big toe could be deployed in another orthotic.

Rigid running shoes will be helpful; minimalist will be a challenge; Saucony Mirage is the level of flexibility you are looking to match...more drop won't hurt either. Wide toe box with custom or good OTC orthoses (modified) will the goal of moving fulcrum for toe break backwards and reducing MTP dorsiflexion.

Avoid inclines until the symptoms are down; and get a get gait analysis to assess pattern as you may want to consider slowly modifying strike/push-off pattern to reduce forefoot load. Ex: a more hip driven push-off with a midfoot strike. I usually don't screw around too much with pattern; unless it can be associated with an injury or prevention.

For the orthotic, you need to see a specialist as an assessment of your entire foot and the rest of the chain needs to be considered to make the right solution.

P.S. Get cleat extenders (move cleat backwards) for your bike shoes to offload forefoot.

Cheers!

As I mentioned before, your "final" diagnosis appears to be arthritis of the 1st MPJ (hallux rigidus) but that should have been diagnosed on your initial X-ray. MRI was not that helpful.

I don't think your running career is over, but you are likely going to accelerate your DJD with certain activities. The stiff carbon plate was a good idea to try if tolerated (my experience is roughly 50/50 tolerate it). Might want to at least use it day to day and then just run in a stiffer shoe. Avoid very flexible forefoot or current fad type shoes. The topical stuff also a good idea to try, but not likely to be all that helpful. There are surgical options to consider if you really can't run.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Still digesting what the doc said on Monday. As i said previously Dr. Roof, the doc didn't say anything about the X-ray that he took. Mostly he spoke about the arthritis after reading the MRI impressions. He tested my toe by moving the bones - it hurt - and he said that was because it is bone on bone.
I put the carbon plate in my Hokas and will discuss orthotics next with week with his orthotist. I did try to run on the soft treadmill at the gym and i guess this is what i have to get used to. I hope that when i get orthotics and try some more rigid shoes and get used to the carbon plate and with some time, the symptoms will ease somewhat if that is a possibility. at this point time, i do not want to consider surgery. i am 62 years old and don't want to tackle that just yet.

do you think the hokas are good for first MTJ pain? are there other rigid shoes (rockers) that you recommend?
gonna try a walk run tomorrow morning and asses.
thanks so much. arthritis is a scary diagnosis to me.

Hokas are fine. No need for a stiff shoe if you are going to use the plate (that is what it is for).

I've had some runners actually like Newtons because the plantar lugs actually help the foot "come over" the 1st MPJ that you want to limit motion. You may consider trying them if you want to continue to run. If running on a treadmill, avoid high inclines and "sprint" intervals.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Not to hijack your thread but I also recently learned that I have a 2nd MTP plantar plate tear - it occurred on Nov 1. I took a month off running and recently started running again in Altra's and in the Hoka Huaka. Its still sore but improving. I injured it while running in the Nike Vomero 10. I loved this shoe but in retrospect it has an extremely aggressive toe spring which I believe contributed to the injury.

VA Guy, I've been dealing with big toe joint pain in my right foot for about 18 months now. Got an X ray a few months back and was diagnosed with Hallux Limitus (partial arthritic joint). I've been able to manage it with Hokas (which have a rockered sole that limits bending of the big toe) and one of these inserted into my right shoe, which you can't even feel:

http://indianabrace.com/turftoe.aspx


Sometimes the joint still hurts after really long runs (15 miles plus), but again, it's manageable, at least for now. Good luck!

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My business-eBodyboarding.com

thanks TriBodyboarder. i did my first run in a month with the carbon plate inserted into my right foot. i find the carbon plate is really too hard and hurts the ball of my foot. what is the indian brace made of? is it hard or soft? did you buy the "pro" model? i have an appt. to be fitted for orthotics but i would prefer not to spend hundreds of dollars if there is something i could rig up myself or buy cheaper. who even knows if expensive orthotics will do the trick???

it is encouraging that you can still run with your arthritis. i have been resting for a month but that didn't seem to help much.

I have the runner model. It is VERY thin, like maybe 1mm thick and has a little flex throughout, but is stiff where the big toe goes and that depression in the big toe area plantar-flexes the toe so it's not bending so much at toe off, and when combined with the rocker sole on the Hoka, works well. If you want stiffer, go with the Pro model. With the standard insole that comes with the Hoka, I can't even tell the difference in feel between the right and left feet.

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My business-eBodyboarding.com

Just curious if these might be plantar plate tear symptoms:

- Soreness under 2nd metatarsal head
- Sharp/shooting pain in 2nd toe
- Pain on push off when running
- 2nd toe bending towards 3rd toe (early stages of hammertoe)
- Pain under 2nd metatarsal head (feels like no padding under the bone) sending shooting pain through 2nd toe when walking barefoot on hard surface
- No pain cycling or skiing, some pain pushing off the wall swimming at times.

X-Ray was clear other than slight hallux valgus and hammertoe. No MRI yet. I'm seeing my orthopedic foot and ankle doc next week. I'm frustrated with this new foot pain since I was feeling back to normal after tarsal tunnel surgery last Feb. I'm wondering if some muscle/gait imbalances caused this latest foot issue.

Yes, they certainly do. But, there are a few other possibilities in your differential diagnosis as well.

X-ray will not show a plantar plate injury, though some clues can be gleaned from it and you have a couple (pre existing hallux valgus, slight drift of the 2nd toe, etc.)

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

That's what I'm afraid of and I appreciate your insight. I guess I'll find out more next week when I see the doc. This has not been a good couple years for me and feet injuries but I guess based on this thread I'm not alone with my current injury.

Take my advice FWIW as I don't know this insert and the magnitude/details of your issue, but I do know these problems quite well in avid runners. Off loading (cut-outs, pockets, shelves...), be it the for the 1st ray relief or for lesser mets (metatarsalgia, capsulitis, plantar plate tears...) can be a slippery slope in runners. They usually provide symptom relief (often immediately) but just know that load isn't going away it is just going somewhere else, so be sure the somewhere else areas are up for the challenge over time.

Reducing dorsiflexion and distributing load is less of a trade-off.

YMMV...literally:)

Happy New Year ST'ers!

Appreciate the comments. I did see immediate relief with the X1 plate when I got it last May, and so far, no ill effects to the other toes, which of course are now bearing much of the load. I realize this is a temporary fix though and I'm just trying to stave off the inevitable.

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My business-eBodyboarding.com

well things have changed in the last week. i went for a second opinion because i was kind of irked that the foot surgeon did not even look at my MRI sans. all he did was read the radiology report. i was fitted for orthotics but have not gotten them yet. i have continued to run. there is pain but not enough for me to stop running. the new doctor and his fellow looked at my MRI and took another foot X-ray. He said that my arthritis was not bad but as he scrolled through the MRI scans, he saw something and he said it was an OCD lesion, a small hole in the bone. i was super surprised and was taken aback at this new diagnosis. i barely was able to hear what he said to me following this. so i really do not know what to do. i plan on calling him tomorrow and hoping that he will call me back so i can ask him questions that i wasn't able to ask at the appoint.

dr. roof may you could shed some light on OCD lesions? i googled and learned most of them are in the ankle. will conservative treatment (in a boot) work or does it pay to just go ahead with surgery? i did hear the second doctor say that surgery would entail micro fracture. do these lesions heal? do they move? what if i continue run? what are the ramifications? i am wondering if i should run until i really hurt and really need surgery? does that make the lesion worse, bigger?
i am so confused and am hoping dr. roof you could help. i do plan on calling the doc tomorrow. should i even talk the first doc?

thanks, still in shock by this new diagnosis.

Is the OCD in the 2nd met head or 1st? Yes, more common in the ankle/knee, but can be anywhere. If so, this chronic overloading of the 2nd MPJ is just a continuation of the chronic 2nd MPJ pain: overloading > capsulitis > plantar plate injury > DJD (OCD) > Frieberg's infraction, etc. More acute overloading leads to a 2nd met stress fracture (very common in runners).

Treatment plan needs to address both your current issues (wherever you are along this timeline) and the future since I assume your plan is to return to running. This needs to be carefully discussed with your physician(s). Osteochondral defects to not "heal" as humans do not have the ability to regenerate articular cartilage. However, with procedures like microfracture or subchondral drilling, you can get replacement by fibrocartilage which can then make the joint asymptomatic.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

t this is the first met. head. there is no plantar plate tear, no ligament tears. doc said not much arthritis either. he did say he saw the bone bruise on the scan.
what do you feel is the success rate of being in a boot and off the foot. if the lesion won't heal itself, what's the point???
would continuing to run make the lesion larger?
i'm trying to put a call into the doc to see if he will answer some of these questions.
thanks a lot dr. roof.

That's right, you were a an initial "turf toe" type injury. Plantar plate issues (thread title) common in runners, but usually the 2nd MPJ.

Osteochondral lesions of the 1st met head not that uncommon a finding. They may or may not need any treatment - purely based on symptoms (which I assume you are having) or you wouldn't be seeking treatment/options. Since you state your plain film X-rays are clear of obvious JDD and just the OCD on MRI, definitely something to address with your doc(s).

As for being in the boot until it "heals" it certainly may. The OCD won't resolve, but it may become asymptomatic in time if you can offload the area long enough (CAM boot, stiff carbon sole, etc.) I'd certainly try before surgery, especially microfracture or OATS type procedures since a very long healing process.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

what would be the ramifications of my continuing to run until the pain gets to unbearable with new orthotics and carbon plate, ice, etc

Probably nothing really assuming you aren't altering your gait a bunch and causing other issues from running on the lateral side of your foot (i.e. peroneal tendonitis, IT band syndrome, etc.). Since your osteochondral injury was presumably caused from a traumatic even and not advancing arthritis, it won't likely get worse quickly. Surgery always an option down the road anyway if pain limits your desired activity.

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

Question for you. I had an MRI and the interpretation is a suspected partial tear of the distal plantar plate of the 3rd and 4th MTP. I first noticed my 4th toe on my right foot would mildly "click" over maybe a year and a half (or more) ago. It never really effected me much until the fall of 2018. Last winter, I had off and on issues running (felt like sock bunched up or stone in my foot - typical morton neuroma sign) but biking was perfectly fine. In the spring of 2019, biking started to become annoying in the right foot where this "clicky" thing was happening. My issue kinda progressed all season this year to the point where I can no longer bike longer than 60 minutes (usually 30' in is the point where things start bio-mechanically going downhill. Toes want to curl up and press into my shoe, arch lifts and then get crampy foot/muscles). It seems like I've lost my ankle stability both on the bike and run and this has now caused annoying bio-mechanical issues biking and running.

I guess my question to you is if you had problems cycling or just running? Does anything I just said about biking sound relatable to you?

I'm seeing a sports medicine doctor next week, but reading through this thread has been helpful to at least tell me what I can expect during this troubling time. Sounds like surgery is not the road I want to have to go down, but I am at a point where I feel that might be my only option. Time will tell I guess.

Andrew,

I have been diagnosed with a "suspected partial tear of the distal plantar plate of the 3rd and 4th MTP". I described a bit of my situation in the post right before this. Do you have any opinions on whether a partial tear can be corrected through treatment or extensive rest or is surgery the only way to fix this? I'm in the Toronto, Canada area. If surgery, do you have any recommendations up in this area for people to visit? I'm meeting with a respected sport medicine doctor next week in my area, so maybe know more then, but just curious on your thoughts.

Thanks,
Luke

I've never seen a tear (partial or full) of the 3rd and 4th plantar plates. That would be exceeding rare and I see a lot of these (just repaired one today - a more common, complete 2nd)

You symptoms (and location) are certainly consistent with a classic Morton's neuroma.

True plantar plate tears don't generally heal on their own, though symptoms can be mitigated by a lot of things (though running/cycling is not one of them) :(

Make sure to get a firm diagnosis before intervention (despite your MRI)

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Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD