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Plantar Plate Injury

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The plantar plate is a thick fibrocartilaginous ligament on the underside of the lesser toe joints (metatarsophalangeal joints), most commonly the second toe. It provides stability and cushioning at the ball of the foot. When it tears or becomes weakened, the toe can become painful, unstable, and eventually drift out of alignment.

Symptoms

• Pain and swelling at the ball of the foot, particularly under the second or third toe
• A sensation of walking on a lump or pebble
• Tenderness directly under the affected metatarsal head
• The toe may appear to lift or drift upward or sideways over time
• Difficulty wearing certain footwear
• Symptoms that worsen with walking, standing, or pushing off

Causes

• Repetitive overloading of the forefoot — common in runners and those who stand for long periods
• A long second metatarsal placing excess stress on the joint
• High-heeled footwear increasing pressure on the ball of the foot
• Flat feet or high-arched feet altering load distribution
• Associated conditions such as hallux valgus (bunion) destabilising the lesser toes
• Acute injury or trauma to the toe joint

Diagnosis

Diagnosis is made by clinical examination — a positive Lachman test of the toe (testing the stability of the joint) is a key finding. Ultrasound or MRI is used to confirm the tear and assess its severity. Weight-bearing X-rays help rule out bony causes and assess toe alignment.

Non-Surgical Treatment

• Strapping or taping the toe to reduce stress on the plantar plate and prevent further drift
• Metatarsal pad or offloading insole to reduce pressure under the affected joint
• Stiff-soled footwear to limit joint movement
• Anti-inflammatory medication
• Physiotherapy to address contributing biomechanical factors
• Corticosteroid injection — used cautiously as it may weaken the plantar plate further

Surgery

Surgery is considered when conservative treatment fails or the toe has become significantly deformed or unstable.

Plantar plate repair involves direct surgical repair of the torn ligament through a small incision on the top or sole of the foot. The plantar plate is reattached and any associated bony deformity or metatarsal length discrepancy is corrected at the same time.

In some cases, a Weil osteotomy (shortening of the metatarsal) is performed alongside the repair to reduce tension on the joint and improve healing. Associated hammer toe deformity may also be corrected at the same time.

Surgery is performed as a day case under general anaesthetic.

Recovery

Timeframe	What to Expect
0–2 weeks	Rest, foot elevated. Post-operative shoe. Wound kept dry.
2 weeks	Wound review. Sutures trimmed or removed. Continue post-op shoe.
2–6 weeks	Walking in post-op shoe. Toe may be strapped to maintain alignment.
6–8 weeks	Transition to wide, supportive trainer. Physiotherapy begins.
8–12 weeks	Gradual return to normal activity. Swelling may persist.
3–6 months	Return to sport and full activity if healing is complete.