#415 Do I need crutches after PRP for plantar plate injury? - DOC

#415 Do I need crutches after PRP for plantar plate injury?

Today on the Doc On The Run Podcast, we’re talking about whether or not you might need crutches after a PRP injection for a plantar plate injury.

I was just doing a telemedicine visit for a second opinion with a runner who’s had a longstanding plantar plate sprain. These can be very frustrating injuries because if you don’t treat them appropriately or you ramp up your activity too early, well, it can recur and they can go on for a really long time.

Now, I’ve had one myself. I got one running on the Dipsea Trail, which is a very, very steep trail with lots and lots of steps. And basically pounding into the edge of those wooden steps, running fast downhill, I got a plantar plate sprain. And it actually took me several weeks to get it to completely calm down, and I’m pretty sure I knew exactly what to do. I did continue running through that time, but I was very cautious about reducing the stress and strain to the plantar plate ligament while I continued to maintain my running fitness as I recovered from that injury.

But again, I’m very, very cognizant of it. I think about it. I think about running biomechanics all the time, and so I was paying very close attention to what I was doing, and I know I was doing everything right, and I was vigilant. Again, still took several weeks to get it better while I was recovering from it.

If you get one that goes on for months, you can get into a really difficult situation where you’re basically at the point where you think you can’t run anymore, and this is what happened with this runner on this telemedicine visit. It had been a long time since he’s running, he needed a second opinion, he wanted to know whether or not the PRP injection, or a stem cell injection, or dry needling, or some other procedure might actually help him.

Part of the questions he asked involved the care after a PRP injection, or a stem cell injection, or a dry needling procedure to try to actually stimulate some new healing and stimulate some new collagen repair in the plantar plate ligament when you’re trying to get it to heal and it’s been a chronic injury.
What I was explaining to him is that I do these treatments a lot where we’re trying to take a chronic injury and get it to heal, and the truth is that I don’t think I have anything magical. You don’t need to fly from New York to San Francisco for me to see you to have one of these procedures. There are always people in your area who can do the procedure for you. You just have to make sure that they do the procedures frequently and they’re used to working with runners.

That’s all you really need, but he was asking me about crutches and he said, “Do I really need to use crutches? Do I need to stress it? Do I need to apply strain to it the same way that you would a recovering Achilles tendon? What’s best?” And I put it to him really simply.
I just said, “Look, here’s the deal. If you haven’t been running for a year or six months or two years or some other long timeframe, you’re really losing a lot of fitness quickly, and you’re getting into almost a point of no return. So, if you’re going to have a procedure that is invasive, even though it’s just a needle, it is invasive. If you’re having a PRP injection, or a stem cell injection, or something like that, if you’re going to go through that procedure, you really want to try to give it the optimum chance to get better.” And that means reducing all of the pressure and the stress to that structure so it can actually start to heal and repair; because what we’re talking about doing in these procedures is we make tiny little holes in the planter plate ligament.
That means use a needle and when the needle is sharp and it has a sharp edge to it, and when we go through the ligament, every time we do an injection, it actually lacerates and cuts or tears some of those little bitty collagen bundles. And that means that you’ve got actually more of an injury right after the injection then you had before the injection. And so, although we’re trying to stimulate a new repair process to take over to replace that chronic, non-healing process, well, it is an acute injury and you really want to let it heal.
If you cut your arm and you pick at it, you pull out it, you stretch the skin, it’s not going to heal very quickly; but if you protect it, you stabilize it, you bandage it, you put Steri-Strips or sutures in it, it heals a lot faster because it’s able to repair without movement. And so I think that initially for people, it depends on the situation, but in most cases what I do is I do have people use crutches. I have them immobilize the foot completely. I have them stabilize the foot and stabilize the plantar plate ligament with a special technique of taping and all the combination of these things hold it completely still in the correct position to actually get some collagen to have a better chance to start forming a repair of the original injury and the acute injury caused by the injection itself. That means no pressure, no tension and no movement to try to actually get that jump-started.

 And so for a process, usually somewhere around a week, again, it depends on the athlete, it depends on their circumstances, but in general, the short answer is yes. I would use crutches initially. Not for six weeks, not for 12 weeks, but for a short period of time to really protect and allow that ligament to actually start to heal and facilitate a true repair of the plantar plate ligament.

You have to remember, this is one of those things where a lot of doctors will do a PRP injection, and if it fails, they tell you, “You failed. It’s not going to work. You just need to do surgery.” If that’s really the case, you want to give it the best possible chances of healing so you can get back to running as quickly as possible, even if that means using crutches for a short period of time.