#559 Does a crooked toe mean plantar plate surgery in a runner? - DOC

#559 Does a crooked toe mean plantar plate surgery in a runner?

Does a crooked toe mean you have to have surgery for a plantar plate injury? Well, that’s what we’re talking about today on the Doc On The Run podcast.



This is a great question I got from someone recently who had a plantar plate injury and the toe was a little bit crooked. His question was, “Do I really need to have surgery if my toe is crooked? Is that a good indicator of whether or not I need plantar plate surgery just because the toe is sitting out of position a little bit?”

Well, I thought it might be helpful to explain to you when it might actually be necessary to have surgery and when it might not be necessary to have surgery. So there are a couple of ways to look at this. I’m going to draw some pictures to show you. My handwriting’s terrible. If you hate it, go ahead and comment on it. My drawings are worse. So feel free to comment on how terrible my drawings are, too. I’m not an artist. I’m a foot doctor.

Anyway, here’s the thing. So the first thing that you have is if you have your foot and let’s say this is the big toe and this is where the second toe is sitting normally. The third toe is sitting here and so on. Let’s say that the deviation in the toe, the positioning of the toe that you’re talking about, is that the toe’s sitting over this way. So that the toe is actually moved over, let’s say, in this direction so that it’s sitting over here like this.

Well, what would that mean that could have happened? Well, one thing that could have happened is that since the plantar plate ligament is basically rectangular on the bottom of the foot, if you had a tear in the plantar plate ligament over here, and that tear opened up such that the ligament was doing this number, well, that gap would actually allow the toe to deviate in that direction. So that might be one indication that you could have a tear in the plantar plate ligament that is actually warranting surgery.

Now there is another circumstance where that may not be true. Let’s say you have swelling in the joint capsule and so, if you imagine, again, this the second toe, here’s your big toe. If the swelling in the joint capsule, it actually gets inflated, well, the swelling when the second toe is bumped up against the third toe here, sometimes we have the swelling. It basically pushes the toe and deviates it in this direction. So you could have a situation where you have swelling within the joint capsule because of a capsulitis or a mild plantar plate sprain, where it’s not really a positional thing because the ligament has ripped and pushed the toe or allowed the toe to drift in that direction.

If you reduce all of the swelling in the joint, if you do some of the stuff I show you in the plantar plate sprain course, and the swelling all goes down and the toe actually moves back to its normal position, then you know that was not a thing where the integrity or the structure of the plantar plate has been compromised in a way that means you have to have surgery. It just means the toe is so swollen, it’s pushing the toe in the wrong direction so it looks crooked.

So if it moves back after the swelling is gone, no, I don’t think you need surgery. Now if it stays the same after you reduce the swelling, that’s more suggestive of one of these types of tears where the ligament might be compromised and allowing the toe to drift over because it’s weaker in one part. That’s one instance.

Now let’s talk about another scenario. Let’s say if you have deviation in a different direction. This is actually what we call transverse plane deviation. If you have transverse plane deviation, that really is not as alarming to most doctors as if you have sagittal plane deviation.

What’s sagittal plane? Well, Sagittal’s from the side. So let’s say this is your foot and this is your toe sitting out here. So here’s your foot, this is the second toe and what we’re looking at when we’re talking about the plantar plate injury is only a few things. You have the second metatarsal bone sitting here like that. You have the proximal phalanx bone, the intermediate phalanx bone, and the distal phalanx bone. Then you have the joint capsule and the thickening on the bottom of the joint capsule that we refer to as the plantar plate.

If you have deviation of the toe in a sagittal plane direction, meaning that the toe is starting to drift upward, then that’s different. So what we assume is that you’ve got a tear in the plantar plate ligament if you have an actual through and through tear where it’s completely ruptured down on the bottom like that, well, then what will happen? Well, the ligament will actually spread apart. So then, again, just reproducing the same important parts here. If you’ve got the joint capsule and the thickening of the plantar plate is actually ripped, it means it allows the toe to drift upward.

If the toe starts drifting upward and you get a hammer toe, because it’s actually torn down here, well, that tear is allowing the toe to move upward because the joint is not held in position like it’s supposed to be by the plantar plate. So if you have a hammer toe forming that looks like that, then you might need surgery to actually repair it. But there is another circumstance where you can get some swelling that causes a deviation that’s not that alarming.

If you did a second opinion and you said, “I think I have a plantar plate injury. I want a second opinion. I did the stuff in the plantar plate course. I’m still not sure exactly what I’m doing because I saw a doctor that conflicted with what I thought I had,” I would tell you to send pictures to me so we could talk about them during your consultation. One of the pictures I’ll have you send is where you’re standing there and I can see your toes straight on like this and so, we’re looking straight at your toes as if you put the camera on the floor and you’re standing on maybe a bathroom scale or something.

If you say, okay, you’re standing there and you’re looking at the toes, and the second toe is sitting up like this relative to the ground and it’s elevated in that position where your second toe on your left foot is actually a little bit higher but it’s straight, the toe’s actually straight. So we’re just seeing this. The toe is up a little bit, but it’s not really crooked. It’s not cranked into a hammer toe then that also is probably from swelling.

So if you have a deviation where the toe is just lifted a little bit, because there’s a lot of swelling on the bottom and it pushes the toe upward, but the toe stays relatively flat, it’s just not actually touching the ground anymore, that also is one of those things we’ll probably improve and the toe will come back down if you can just get the swelling out of the joint. If you have a reduction in the swelling and the toe comes back to the ground, less likely that you would need surgery. Then the other thing, of course, to think about is whether it’s painful or non-painful, no matter what’s going on. If you don’t have pain, even if you have a little deviation, why in the world would you want to do surgery?

Just because something is crooked or a little bit out of alignment or something, if it doesn’t cause you pain and it doesn’t interfere with your activity, to me, the idea of doing surgery is basically crazy. So I would not generally recommend that. There are probably some unique circumstances where that’s probably not the case, but you have to really think about this. If it doesn’t interfere with your activity, you could have surgery and wind up with a different problem as a post-operative complication that makes it difficult for you to run later.

Those are things you really need to think about when you’re considering deviation in the toes and whether or not it might actually be an indicator of you needing surgery. So if you haven’t seen it yet, go check out the plantar plate master class. It’s a deep dive, about half an hour, where I go through all the stuff you really have to think about if you’re a runner with a plantar plate injury and you’re trying to stay active. Just go to docontherun.com/plantarplatemasterclass, and you can join me free there. I’ll see you in the training.

Also, if you enjoyed this episode, if you found something useful from this, or if you watch this because you have a friend who has a plantar played injury, who’s too bummed out to figure out what to do, please like it, share it, comment, send it to somebody who might find it useful. Then I’ll see you in the next training.