#499 Why plantar plate injuries get misdiagnosed so frequently in runners - DOC

#499 Why plantar plate injuries get misdiagnosed so frequently in runners

Today on the Doc On The Run Podcast, we’re talking about why plantar plate injuries get misdiagnosed so frequently in runners.


Every time I do a second opinion consultation with a runner who has a plantar plate injury, I hate to tell you this, but I hear the same story over and over and over. Basically they call me and they say, “Well, I have a plantar plate sprain. I know I have a plantar plate sprain. I went through the plantar plate sprain course and I’ve been doing some of those things to actually try to get it better and it’s starting to improve, but I was misdiagnosed with another condition.” And we’re going to talk about why runners get misdiagnosed so frequently when they have plantar plate injuries and why it can be difficult to figure out whether or not that’s actually a problem in the first place.

Stress Fractures

Well, the first thing I’ll tell you is that the most common thing that runners get misdiagnosed with when it’s a plantar plate sprain is a metatarsal stress fracture. Part of the reason for that is that metatarsal stress fractures are so common in runners.

So when you go into the doctor and you say, “My foot hurts. I’m running, I’m training for a marathon, I’ve been ramping my mileage up,” and you give them the story that says you’ve been increasing the load to your foot systematically through your training efforts getting prepared for a big event, well, the doctor is going to immediately think stress fracture first thing.

That’s where we get into trouble is that part of the process that we’re taught as physicians about how to actually diagnose your injury when you have one is this thing of listening to your story and trying to think what things actually fit with that best and overwhelmingly stress fractures are the most common thing that it could be in the foot when you’ve been increasing your training load. So that’s one of the reasons that you get misdiagnosed.

Extensor tenosynovitis

The second thing is you get misdiagnosed with something called extensor tenosynovitis and that sounds like a big complicated term, but it’s really not. What it is is you have tendons on the top of your foot that go across to pull up the toes that go right across the metatarsal bones. If you look at your hand and you look at the back of your hand and you pull your fingers up and spread them, you can see the extensor tendons that go to the fingers actually spreading across the back of your hand. Well, when you look at that and you see them, if you actually squeeze the tendons, you’ll feel something hard under the tendons and that is the metatarsal bone. In your hand, it’s actually called a metacarpal, but you get the point.

So what happens is that sometimes just from having the laces too tight on your shoes or having really thin round laces on your shoes when there’s not much padding in the tongue of your running shoe, it will actually compress the tendon sheath that that tendon slides through. When that happens, it swells and it starts to become painful. and that is on the top of the foot right over that area. Sometimes people get misdiagnosed with that, but the truth is that’s pretty far away from the plantar plate. So if somebody tells you you have extensor tenosynovitis on the top of your foot but your pain’s on the bottom of the foot, you definitely need a second opinion.

Intermetatarsal Neuroma

The third thing that I actually see runners get misdiagnosed with when they have a plantar plate sprain is a intermetatarsal neuroma. Now, this is really simple. I actually made some 3D animations that show you the anatomy of the plantar plate ligament and explained to you where it is, why it hurts, how to test it, how to stress it, how to strain it, and how to figure out whether or not it’s getting better in the Plantar Plate Sprain for Runners.

We discussed a lot of this stuff in the Plantar Plate Masterclass that you can get for free and sign up and I spent like a half an hour or so talking about it in great detail, but the neuroma is a thing that happens in a nerve goes right between two of the plantar plate ligaments. So if you have a plantar plate sprain let’s say of the second metatarsal and it seems like the pain when the doctor pushes on the foot in between the two metatarsals causes discomfort because some of the ligament at the side of the joint is actually inflamed, then sometimes can seem like a neuroma when really it’s a plantar plate sprain.

The truth is is that in the beginning part of the plantar plate injuries, many athletes really don’t have that much pain. It’s kind of swollen, it kind of hurts, it’s kind of sore, but it’s not really like it’s killing you. And so when you come in with this vague description of pain and it’s kind of hard to reproduce the pain when they poke around on your foot, many times the doctors will think that’s a neuroma instead.


Now, the fourth thing that gets misdiagnosed when you have a plantar plate sprain is a condition called capsulitis. Now, capsulitis just means you have inflammation or swelling and irritation of the joint capsule that holds the fluid inside the joint. Now, the problem with this diagnosis is that the plantar plate ligament is basically a thickening of the joint capsule on the bottom of the foot right where the toe connects to the foot. So if you have a plantar plate injury, technically you should also have capsulitis.

Now, why am I telling you this? Well, there’s a real problem that happens when the doctor says, “Oh, you have a diagnosis of capsulitis. You have some inflammation within that joint. So what we’re going to do is we’re going to inject a corticosteroid solution into that joint to calm down that inflammation in the joint. Then the joint will feel better, it will leave you alone and you can go about training for your marathon again.” That sounds great. So you say, “Great. Inject it.”

Then the doctor injects it with corticosteroids, but you not only have capsulitis on the inside of the joint, you have it because you had a tear or a sprain of the plantar plate ligament on the outside of the joint. If that has happened and you inject corticosteroids in there, it can actually weaken the collagen and the plantar plate sprain can actually get bigger and tear more. And that is a serious problem.

If you think you have pain on the bottom of your foot and you might have a plantar plate sprain, you should definitely go through the Plantar Plate Masterclass to check it out. If you really want to know all the detail, of course you can go through the Plantar Plate Sprain for Runners where I talk about everything that I would tell you if I was seeing you in-person in terms of how to figure out whether or not it is a stress fracture or a neuroma or just capsulitis or a true plantar plate injury, and then of course, what to do to get it to calm down so you can get back to training. But just remember if you wear a fracture walking boot for four weeks and then it doesn’t get better and then the doctor diagnoses you with a plantar plate sprain, you will have lost months worth of training just during those few weeks of immobilization.

So if the doctor threatens to put you in a boot, get a second opinion, go through the Plantar Plate Masterclass, or go through the course for runners. You really got to make sure that you don’t get treated in a way that’s not going to be helpful that’s really going to kill your running fitness because maintaining your running fitness while you’re healing from any overtraining injury is the best way to get back to running quickly.