#578 Did my doctor do the wrong plantar plate injection? - DOC

#578 Did my doctor do the wrong plantar plate injection?

I think my doctor did the wrong injection for the plantar plate ligament. That’s what we’re talking about today on the Doc On The Run podcast.



If you get a plantar plate sprain, and you have all this pain and irritation at the ball of the foot, right where the second toe attaches to the foot, it could be a plantar plate sprain. If you get a plantar plate sprain, you might be inclined to go see a doctor and then ask them to do something like an injection that might actually help it get better faster, particularly if you’ve got a race coming up.

A one common injection performed for plantar plate ligament sprains is actually a corticosteroid injection and a corticosteroid injection just reduces the inflammation, which helps to reduce the pain and swelling that you have at the ball of the foot. Now, this is a question that actually came from somebody who had an injection, they saw a podiatrist, the podiatrist did a corticosteroid injection for the plantar plate sprain and then the patient actually asked me if the doctor did it wrong, and I’ll explain why.

When you have a plantar plate ligament sprain, it’s on the bottom of the foot. If you look at your foot, and if we’re looking at the second toe, this is a cross-section through the second toe, you have the metatarsal bone and the proximal phalanx bone and the intermediate phalanx and the distal phalanx bone. Then you have the joint capsule. The joint capsule holds all the fluid in and the planter plate is down here on the bottom. Now, the question was, is, did the doctor do it wrong?

The reason this person thought the doctor might have done it wrong was they said, “Well, all my pain, all the pain I’ve had all along is all down here. This is where it hurts, all on the bottom. It hurts when I push up on it, it hurts when I stand up on my toes, it hurts when I do pushups and bend the toe up in this direction,” which of course stretches the planter plate ligament, and that causes pain in this area and so this person had an injection and said that they were concerned that the doctor didn’t know what the doctor was doing and may have done it wrong because they went in and they took a syringe and they did the injection from this direction and went right into the joint at the top to squirt corticosteroids in there. Was that the wrong thing or not?

Well, yes and no and most of the time, if you have a planter plate sprain and you have a corticosteroid injection, it’s not just because you have the plantar plate sprain itself. In fact, if you get a statement from the doctor and you have the planter plate sprain as your diagnosis that they tell you, you may look at your invoice, and if you look at the codes on there, you may see one that is labeled capsulitis. So capsulitis is inflammation of the joint capsule, and the planter plate is a thickening in a ligament down reinforcing the plantar or bottom side of that joint and on the planter side of the joint is where the ligament is, and so most people think since they have pain down here, you should do the injection down here. Well, there’s two reasons why the doctor may have done that, and one reason why you might not want the injection done on the bottom.

If we assume that you have inflammation within the joint and that a lot of your pain is not just from the planter plate ligament sprain, but it’s also from the inflammation of the lining of the joint called the synovial tissue that makes the synovial fluid that lubricates the inside of the joint, well, then we inject the joint capsule and why would we inject from the top? Well, number one, if you go from the top, it’s easier to get into the joint first of all. Less likely to hit the cartilage if you go in from the top and damage the cartilage. It’s easier access number one, number two is that you have inflammation of the lining of the joint all on the inside and if you go from the top, it’s going to put that all on the inside of the joint, it’s going to be in the top, it’s going to be in the bottom, would be all in that area, inside the joint to stop the inflammation.

If you go from the bottom and you inject, number one, it’s a small needle, but it is a sharp needle and it is putting a hole through the bottom of the joint where the planter plate is, so you’re actually making a new hole and another hole and another injury to the planter plate ligament when you inject it from the bottom. Also, if you inject it from the bottom, part of the problem, and part of what your doctor’s worried about is that when we remove the needle, that some of the corticosteroids are going to leak out into this area around the planter plate ligament on the bottom.

Now corticosteroids are the best thing that we use to inject into joints and stuff to decrease inflammation. They’re also great at breaking up collagen bonds. So if you have a scar tissue area that’s really too stiff and too big, or inflamed, or irritated, or prominent because of collagen in the scar tissue, we might inject it with corticosteroids to dissolve some of that collagen and shrink it down.

You do not want to shrink down or dissolve the planter plate ligament though, and so the corticosteroids, when they’re injected around the planter plate ligament, or if you inject in the bottom and it diffuses out around the planter plate ligament, then it can make it weaker and weaker is not better, you want it to get stronger and you want it to heal. Also, the corticosteroids stop the healing of that ligament for a little while and the more of it you have injected on the bottom, the more that’s true.

The short answer to this question is that now if somebody injected the top of your foot for a planter plate sprain, even though the top is the dorsal part and the bottom of your foot is the plantar part, it’s still probably the right injection, so the doctor, in all likelihood, did do the right thing and considered all these variables when deciding which of these options would be best for you.

If you have not checked it out yet, if you’re a runner and you have a planter plate sprain and you’re trying to figure out how to get back to running, you got to check out the Planter Plate Master Class. It’s a free 30 minute web class where I go into a deep dive about all of the things you need to really understand as a runner who wants to get back to running as quickly as possible when you have a planter plate injury. You can check it out for free at docontherun.com/plantarplatemasterclass. Go check it out and I’ll see you in the training.