Ruptured plantar plate

by Carlene
(Australia)

Hi,

I stood on a bounganvillea thorn about five months ago and have been in nasty chronic pain ever since. Have had the usual ultra sound and an MRI which indicates a ruptured plantar plate and bursitis. The orthapaedic surgeon recommends surgery which I am reticent to go ahead with. Was wondering how I could have ruptured it by standing on a thorn and whether there is an effective alternative to surgery. No thorn showed up on Xray. Am desperate.
Kind regards, Carlene

RESPONSE

Hi Carlene,

To start off with, I do not know how you could have torn your capsular ligament (plantar plate tear) by standing on a thorn, but again, I have no idea what a boungancillea thorn is and how long and thick it is.

I guess the bigger issue is you have a torn ligament and a bursitis and it really does not matter how you got it, but rather what are you going to do about it.

One of the problems I have when I answer these types of questions is that I do not know how much pain you are in, nor, in this case do I know what your foot structure is like, since surgical correction is different for different types of foot structure.

Lastly, I do not know what kind of conservative treatment you have had up to this point, if any.

So, making the assumption you are in enough pain to consider surgery, but not so bad that you cannot walk around, you should consider conservative treatment prior to any surgery. Assuming you are reasonably healthy and reasonably young, a torn plantar plate can heal without surgery.

Typically, a plantar plate tear is a worsening of capsulitis, which you can read about on this site. Since both conditions are caused by an overstretching the capsular ligament, one option would be to go into a walking boot for maybe 4-6 weeks; a boot would not allow your toes to bend upwards, which in turn would not allow you to keep stretching the torn ligament and possibly allow it to heal. I use the word possibly, again, because I do not have the luxury of actually examining you.

If you do go into a boot, it is with the stipulation that it is worn 24/7. If you get lazy about it, and start walking around barefoot or even in shoes, the capsular ligament will be subject to stretching and thus your problem will never get better.

Now along with the boot, assuming you can tolerate it, I would also recommend oral anti inflammatory medication to reduce the discomfort. Additionally, You might consider physical therapy of the type where different modalities are used to enhance and speed up the healing process. I would stay away from the type of physical therapy that looks to exercise the foot; that will only make matters worse.

Now, if you end up having surgery, you really need to ask your doctor what he plans to do. Simple sewing back together the torn ligament may not be enough. This would depend on your overall foot structure.

For example, if you happen to have a high arched foot with associated hammertoes, simply sewing the torn ligament back together probably will not be enough, because a high arched foot with hammertoes tends to put a lot of stress on the capsular ligament and you might be destined to have an unsuccessful surgery.

Going forward, after surgery, should you have it, you would also want to be very careful about your shoe selection. You might want to avoid wearing high heels, which tends to stretch the plantar fascial ligament. You would also want to avoid ballerina shoes and flip flops, as well as thin sandals all of which tend to allow the toes to bend more then they should, which once again puts tremendous strain on the plantar capsular ligament making it prone to either hurting or tearing, or both.

If you are not sure about the proposed surgery, my best advice to you would be to get a second opinion by a local doctor.

Marc Mitnick DPM
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