Abstract
Background
Plantar plate injuries are a common cause of forefoot pain and can lead to functional instability. These injuries may be classified as a low-grade (<50 % thickness) or high-grade (>50 % thickness) tear on ultrasound. This study evaluates plantar plate tear severity based on ultrasound and its correlation with surgical intervention.
Methods
A retrospective review was performed on patients with ultrasound-confirmed lesser metatarsophalangeal joint plantar plate tears between 2011 and 2024. Patients were categorized by ultrasound grade of tear and whether they underwent nonsurgical or surgical treatment. A Chi-square test assessed the association between grade of plantar plate tear (low and high) and treatment (nonsurgical and surgical).
Results
Fifty-four patients were included in the study. Of the 23 patients with low-grade tears, 4 required surgery. Of the 31 patients with high-grade tears, 11 required surgery. Statistical analysis revealed no statistically significant difference between plantar plate tear grade and treatment type (χ² = 1.35, p = 0.246).
Conclusion
The severity of plantar plate tear as determined by ultrasound does not independently predict the need for surgical treatment. Treatment strategies appear to be more strongly influenced by patient-reported pain, functional limitation, and patient preference rather than imaging findings alone.
Introduction
The plantar plate is a fibrocartilaginous structure located inferior to the metatarsophalangeal (MTP) joint that provides stability. Injury to the plantar plate can result in partial or full-thickness tearing, most frequently at the second metatarsophalangeal joint, followed by the third and fourth metatarsophalangeal joints. , Etiologies include repetitive forefoot loading, hallux valgus deformity, a relatively long second metatarsal, first ray insufficiency, and chronic lesser MTP joint overload. ,, Clinically, patients often present with plantar forefoot pain, swelling, and a sensation of instability. Physical examination may reveal tenderness at the plantar aspect of the MTP joint, a positive dorsal drawer test, crossover toe deformity, or splaying of the digits. ,
Plantar plate injuries are commonly distinguished as low grade (<50 % thickness) or high grade (>50 % thickness) on ultrasound. Low grade tears appear as a discrete anechoic or hypoechoic cleft in the deep articular surface with intact superficial fibers, while high grade tears appear as a focal anechoic or hypoechoic defect that extends from the articular to the plantar surface. ,
While plain radiographs can rule out bony abnormalities, they are not diagnostic for plantar plate pathology. MRI offers high accuracy but is costly and less readily available. By contrast, ultrasound provides a rapid, dynamic, and cost-effective option with diagnostic accuracy reported between 79 and 100 %. ,,, These advantages make ultrasound an attractive alternative in both diagnosis and grading of plantar plate injuries.
When a tear occurs, management can include both nonsurgical and surgical treatment. There are no clear guidelines as to which approach to take when treating a plantar plate tear. In earlier stages of the injury, plantar plate tears are oftentimes treated with a nonsurgical approach. After failing nonsurgical treatment of plantar plate tears, studies have shown plantar plate tears may be treated surgically with satisfactory results. ,,, A study performed in 2012 by Peck et al. reported no significant differences in outcomes between surgical and nonsurgical treatment of plantar plate injuries in terms of function, pain, and satisfaction. Clinical decision-making regarding surgical versus nonsurgical treatment therefore remains individualized, and guidelines are lacking. It is hypothesized that higher-grade injuries necessitate surgical repair; however, few studies have directly evaluated this correlation. The aim of this study is to evaluate plantar plate tear severity as determined by ultrasound and the correlation with surgical intervention.
Methods
Study design and approval
This was a retrospective cohort study approved by the Institutional Review Board at Loyola University Medical Center.
Inclusion and exclusion criteria
Patients over 18 years of age with ultrasound-confirmed plantar plate tears of the lesser metatarsophalangeal joints between January 2011 and December 2024 were included. Cases with explicit documentation of low-grade or high-grade tears in the ultrasound report were analyzed. Patients were excluded if they had plantar plate injuries of the first MTP joint or no clear grading of tear severity.
Data collection
All patients were treated at a single academic medical center. Ultrasound examinations were performed by certified sonographers and interpreted by fellowship-trained musculoskeletal radiologists. Medical records were reviewed to determine whether patients underwent nonsurgical or surgical treatment. Treatment decisions were based on shared decision-making between physician and patient, taking into account pain severity (numeric pain scale scores were inconsistently documented in the medical record), functional limitations, failure of nonsurgical management, comorbidities, and patient preference. Because numeric pain scores were not consistently available, statistical comparison of pain levels between surgical and nonsurgical groups was not performed.
Surgical cases were performed by multiple foot and ankle surgeons at a single academic medical center. While all employed standard plantar plate repair techniques, specific surgical methods were not analyzed in this study.
Statistical analysis
Chi-square (χ²) analysis was used to assess the association between plantar plate tear grade and treatment type. Statistical significance was defined as p < 0.05.
Results
A total of 54 patients were included in this study. Of the 23 with low-grade tears, 19 (82.6 %) were treated nonsurgically and 4 (17.4 %) underwent surgery. Of the 31 with high-grade tears, 20 (64.5 %) were treated nonsurgically and 11 (35.5 %) underwent surgery. See Table 1.1 below. The Chi-square test yielded a value of χ² = 1.35 (df = 1) with a p-value of 0.246, indicating no statistically significant association between ultrasound confirmed plantar plate tear grade and treatment modality.
Table 1.1
Contingency table displaying frequency distribution of the variables.
| Non-surgical treatment | Surgical treatment | Total | |
|---|---|---|---|
| Low grade tears | 19 | 4 | 23 |
| High grade tears | 20 | 11 | 31 |
| Total | 39 | 15 | 54 |
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