349 Does the plantar plate need to "heal” on MRI before I can run? - DOC

349 Does the plantar plate need to “heal” on MRI before I can run?

Today on the Doc On The Run podcast we are  talking about whether or not you need to see healing of the plantar plate ligament on your MRI before you can run.

I was recently doing a call with an athlete who has a sprain of the plantar plate ligament. Now there are a couple of problems with this because he went and got an MRI. In fact, he got a couple of MRIs. The MRIs were different. They may have been done in different facilities. But the problem is that you don’t get a clear comparison on the healing that’s happened in the months that happens in between those two imaging studies.

The other thing is that when you get an MRI and you see a tear on the MRI you assume a couple of things. The first thing you assume is that the tear on the ligament was not there before your foot started hurting. You have to think about that for a minute because one of the things that happens all the time with runners is we get an MRI, we get a study, sometimes just for what we suspect is a plantar plate sprain. Sometimes it’s for something completely different. Sometimes it’s for a stress response or stress reaction or trying to see if you really have a stress fracture. Sometimes just because you think you have an intermetatarsal bursitis or some completely different condition.

Then what happens as we get an MRI, we get an MRI report from the radiologist and many times those reports say something to the effect of possible interstitial tear of the plantar plate ligament of the second metatarsal. Possible thickening or degenerative changes of the third and fourth plantar plates. Cannot rule out interstitial tear or partial thickness tear of the plantar plates of the second and third metatarsal phalangeal joints. 

The problem is that this does happen all the time. The radiologist sees all kinds of different things on the images that seem to be a problem. And of course when you get an MRI and you see what appears to be damaged tissue, it’s alarming. So a lot of times I end up doing second opinions for runners who have their MRIs and they are not only confused, they’re frightened and understandably so. 

I mean you have a study that says you have all this damage that not only is your second plantar plate potentially torn, maybe your third and fourth as well. But you get confused because you don’t have any pain at all in the third or fourth metatarsal area and so what does that mean. Well what that means is you’re an athlete.

If you get a damage to the joint and it doesn’t repair itself but then you aggravate it because you have what we call an acute and chronic injury where it hurts now, it is swollen now. On the MRI you have the inflammation around the joint that indicates that it’s all irritated and aggravated but you have what may be old injury in the vicinity we presume it’s a new injury and that’s not always the case. What that means is that before you had the study, before you got the MRI, before your foot hurt if you had gotten an MRI you would have seen this partial tear or this little tear or this little area that indicates damage to the plantar plate ligament but you don’t have pains. So it is not actually a problem, it is just damaged but you have been living with that. You have been running with that. You have been training with that. You have been racing with it and it’s not actually a problem.

First and foremost you have to realize that is a possibility you might actually have damage to the tissue around the joint capsule in the plantar plate ligament and it is not really a problem and in that case your goal is not to make the tear disappear on your MRI. The goal is to get back down to where you were before where the area is not inflamed, it’s not irritated and you can run and train and continue to do what you want without trouble. That’s a different goal.

So when you get this damage on the plantar plate and you see it on the MRI, you kind of start to freak out and sometimes that’s completely unnecessary. And if you have what appears to be wear and tear on the second, third and fourth plantar plate ligaments but the other ones never hurt then you can probably be a little more assured that you might be able go to get back to that state where you could still see this wear and tear on your MRI but you will be able to train and run and do whatever you want without any trouble. So you don’t always have to see it completely go away on the MRI. 

The other thing is you have to remember the MRIs are not a hundred percent accurate and that’s probably something for another episode but you have to realize that the structure itself, the plantar plate ligament is very small and when you only have a few slices that are four millimeters apart or three millimeters apart or three-and-a-half millimeters apart. You could get one slice that goes through the plantar plate and you are looking at that one view that is only through this one slice but it’s not looking at the ligament. 

It is also possible on the flip side of that, that you would get an MRI later and because you’re not sitting in the scanner in exactly the same position that the slice that goes through the plantar plate ligament to look at it actually shows an area that was never torn. And so it looks like it’s completely healed because you’re looking at an area that was never torn.

Sometimes people get an MRI hoping that it will look healed and it doesn’t look healed. But it’s actually not a problem. Sometimes people get an MRI following up later after they’re hoping that they’re healed and they get an MRI that has one slice going through the ligament where of course it was never torn and so it looks completely healed. But it’s not completely healed because just next to that area is maybe a little tear that just didn’t get captured by the MRI. 

The MRIs are not perfect. More than anything else you need to be able to tell what’s going on with your foot, know what to track, know how to test it, know how to poke around and manipulate the plantar plate ligament in order to make a decision about when you should ramp up your activity. 

I always rely on your history of healing, your course of recovery, the way that your swelling has gone down, the way that your pain has gone down, the response you have when you try new activities. To me those things are far more important than an MRI in order to determine when you can actually get back to running. So when I do telemedicine, second opinion calls from runners, that’s what we talk about more than anything else. It’s not so simple to just an MRI and say you’re good or you’re not good. That’s really not a safe way to go about this. So that’s a lot of what we talk about in the plantar plate course for runners is how to evaluate things yourself, how to keep track of things yourself so that you can actually make those decisions. And you called me for a Telemedicine visit or second opinion and you sent me your MRI, we would talk about all these exact same things anyway because this is what you have to really understand is that your clinical course of healing is more important than what you see on any image when you’re just trying to get back to running.

Keep very close track on how much pain you have, how much swelling you have, what you’re doing and how much pain you have when you’re doing all those activities. That is way more important than the images that you see and the hope that you may get or the hope that may evaporate when you do get an MRI.

You may find this hard to believe, but most of the runners who call me for a second opinion when they have a plantar plate sprain and they’re just not getting better, and they’re frustrated because they’re losing all their fitness and it seems like it’s taken forever to get better.

When I do a webcam visit, I hate to tell you this but most of the time what I do is I explain to them the exact, same stuff that is in the Plantar Plate Sprain Course. Or you can go to this episode at docontherun.com and you can get access to it.

You can go to the tab that says self-help courses, you can go there. But you can get access and you can get the information that’s going to be most helpful.  I spent a lot of time putting that course together just to make sure you know exactly what to do. And what I show you in that course is exactly what I would do with you if I was sitting in your living room right now.

Just go to docontherun.com, click on the podcast tab, go to this episode or go to the self-help courses and get it now.

Remember, it’s not really that complicated. When you have a plantar plate sprain and you want to get back to running, you need to confirm you have the right diagnosis. 

You need to decrease some stress and strain to the plantar plate ligament, decrease the inflammation around the joint and then follow a very structured return to running that will allow you to retain your aerobic fitness, rebuild your running fitness and prevent you from getting another overtraining injury.

But if you do that, you can heal the plantar plate ligament and keep running!