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Forefoot & lesser toes

Plantar Plate Injury

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Plantar plate injuries are a common cause of pain under the ball of the foot, usually at the base of the second toe. Most people are treated without surgery. This page explains what the plantar plate is, how the injury is diagnosed, the non-surgical treatments Mr Hester most often recommends, in particular toe taping and calf stretches, and when surgery is considered.

What is the plantar plate?

The plantar plate is a thick, tough band of fibrocartilage on the underside of each of the smaller toe joints, the metatarsophalangeal (MTP) joints at the ball of the foot. It is attached firmly to the base of the toe and more loosely to the end of the metatarsal bone behind it. Its job is to support the joint, cushion the ball of the foot and, importantly, stop the toe from bending upwards too far or drifting out of line.

The second toe is the most commonly affected. Problems usually develop gradually from repeated overload rather than a single injury, although a sudden forced upward bend of the toe can also cause a tear. Factors that increase the load on the joint include a long second metatarsal, a bunion, high-heeled or very flexible footwear, a tight calf, and activities that put a lot of weight through the forefoot.

Symptoms

• Pain under the ball of the foot, at the base of the second (sometimes third) toe
• Pain that is worse when walking barefoot, pushing off, walking uphill or wearing heels
• Swelling around the base of the toe, which may be visible on the top of the foot as well as underneath
• A feeling of walking on a pebble or a fold in your sock
• The toe starting to drift towards the big toe, opening a gap between the second and third toes (sometimes called the "V sign")
• The toe lifting so that it no longer touches the ground when standing
• In longer-standing cases, the second toe may cross over the big toe (a crossover toe)

Similar pain can be caused by other forefoot problems, including metatarsalgia, Morton's neuroma, Freiberg's infarction and stress fractures, which is why an accurate diagnosis matters.

Diagnosis

Clinical examination. Mr Hester will examine the foot standing and sitting, check the position of the toes and feel for tenderness directly under the joint. A key test is the vertical stress (drawer) test, sometimes called the Lachman test of the toe: the metatarsal is held steady while the base of the toe is gently moved up and down. Excess movement compared with the other toes, or reproduction of the pain, suggests the plantar plate is damaged. Calf tightness is also assessed, as it increases pressure on the forefoot.

X-rays. Weight-bearing X-rays show the alignment of the toes, the relative length of the metatarsals and any arthritis, and help rule out bony causes such as a stress fracture or Freiberg's infarction.

Ultrasound or MRI. Ultrasound (which can assess the joint while it moves) or MRI is used to confirm a plantar plate tear, judge its size and look for other causes of pain such as a neuroma or joint inflammation.

Non-surgical treatment

The aims of non-surgical treatment are to settle the pain, reduce the load on the injured plantar plate, hold the toe in a good position while it heals, and correct contributing factors such as a tight calf or unsupportive footwear. Treatment works best when it is started early and followed consistently.

1. Toe taping (plantar plate strapping)

Taping holds the second toe pointing slightly downwards (plantarflexed), in line with the other toes. This takes tension off the plantar plate, reduces pain when pushing off and helps stop the toe drifting upwards or sideways while the tissue heals. Your clinician or physiotherapist will usually show you how to do it the first time.

Illustrative image.

You will need: rigid sports tape (zinc oxide tape) cut into a narrow strip about 1–1.25 cm wide and roughly 20–25 cm long. Method 2 also needs a wider strip (about 2.5 cm) to anchor it. Skin should be clean and dry. Sit with the foot resting comfortably and the ankle relaxed.

There are two common ways to tape the toe, shown below. They are alternative techniques: use one or the other, not both. Your clinician will advise which suits you.

2. Calf and foot stretches (posterior chain)

A tight calf limits how far the ankle bends upwards. When walking, the body makes up for this by rolling onto the forefoot earlier and harder, which increases pressure on the ball of the foot and the plantar plate. Stretching the two calf muscles, the gastrocnemius (stretched with the knee straight) and the soleus (stretched with the knee bent), is a simple and important part of treatment.

Illustrative images.

Your physiotherapist may also add gentle strengthening exercises for the small muscles of the foot once pain allows.

3. Footwear, padding and other measures

Illustrative images.

• Stiff-soled or rocker-soled shoes. A firm sole that does not bend at the ball of the foot, or a curved "rocker" sole, reduces how much the toe joints bend with each step. A stiff insole or carbon-fibre plate can achieve a similar effect in some shoes.
• Metatarsal pad. A small dome-shaped pad placed just behind the ball of the foot spreads the load away from the injured joint. If it sits directly under the painful area it can make symptoms worse, so position matters. Custom insoles may be recommended for some people.
• Avoid high heels and flat, flimsy shoes. Heels push weight onto the forefoot and bend the toes upwards; very soft, flexible shoes give little protection. Avoid walking barefoot on hard floors while symptoms settle.
• Activity modification. Reduce running, jumping, lunging and long periods of standing. Cycling (with a stiff-soled shoe), swimming and upper-body exercise are good ways to stay active.
• Ice and elevation can help with flare-ups of pain and swelling.
• Anti-inflammatory medication. A short course of anti-inflammatory tablets or gel may help with pain, if they are suitable for you. Check with your GP or pharmacist first, particularly if you have stomach, kidney or heart problems or asthma.
• Steroid injections: used with caution. Steroid can weaken ligament tissue and may increase the risk of the plantar plate tearing further or the toe drifting. For this reason steroid injections are used very selectively, if at all, and Mr Hester will discuss the risks and benefits with you.
• Walking boot. For a particularly painful flare, a short period in a walking boot is sometimes advised to rest the forefoot.

What timescales should I expect?

Ligament tissue heals slowly, and plantar plate injuries need patience. Many people notice the pain beginning to ease over the first few weeks once the toe is taped and the foot is properly offloaded. Treatment is usually continued for several weeks after that, and it usually takes three to six months for symptoms to settle fully, and occasionally up to a year. Returning gradually to sport and normal footwear helps avoid setbacks. If there is little or no improvement despite a dedicated period of non-surgical treatment, or the toe keeps drifting, Mr Hester will review the options with you.

Stage	What it typically involves
Early (first weeks)	Taping, stiff-soled footwear, metatarsal pad, reduced impact activity, daily calf stretches. Pain usually starts to ease.
Middle (around 6–12 weeks)	Continue offloading and stretching. Taping is gradually reduced if the toe stays in a good position. Low-impact exercise is built up.
Later (3–6 months, sometimes longer)	Gradual return to normal footwear and higher-impact activity as comfort allows. Review if symptoms persist.

These are general guides only. Everyone's recovery is different, and Mr Hester will tailor the plan to you.

Surgery and recovery

Surgery is considered when pain continues despite a good period of non-surgical treatment, when the toe is becoming increasingly unstable or deformed, or when a crossover toe has developed.

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 after surgery

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.

Frequently Asked Questions

Call 020 7046 8004. Private clinics at Devonshire Place, Cromwell Road, London Bridge and King Edward VII's Hospital.

This page provides general information and is not a substitute for personal medical advice. If you have diabetes, reduced sensation or circulation problems in your feet, or sudden severe pain, swelling or redness, please seek medical advice promptly.