Today, on the Doc On The Run Podcast, we’re talking about a runner with a plantar plate injury and deep perineal neuritis.
This was an interesting case that I have here to share with you, and this was a runner who called me for a second opinion and he had a couple of things going on that created a pretty confusing picture for him. And I thought it might be interesting because maybe you’ll have something similar and this might help you out how we worked through it. He had a plantar plate injury, at least he was told he had a plantar plate injury, maybe on not just the second toe, but a couple of toes. And when you get a plantar plate injury, what we’re talking about is when you look at the foot, forgive my drawings here, you get the idea. You have the second metatarsal bone sitting here, third metal tarsal bone sitting over here, and the fourth and the fifth, and so on.
First metatarsal’s over here, and that’s basically the stuff that matters the most. So the plantar plate ligament on the bottom of the foot is a little bitty ligament that is reinforcing the joint capsule down here. Now, he was told that he had injuries to two, three, and four on his MRI. And I’m a little suspicious of that truthfully, but that’s what he was told. So that has my radar going off initially just when he’s told that it’s multiple places. Now, he also has a couple of things that are interesting. On the bottom of the foot, he’s also got, if you’re looking at this from the bottom, he has this very interesting ridge of callus. And the callus is here like this. So he’s got this whole line of callus right at the edge of where that plantar plate ligament is. And why is that interesting?
It’s interesting to me because when we look at the foot from this position, and you think about where the second metatarsal comes down and the plantar plate ligament is down here basically holding the toe down, the plantar plate ligament is down there, you also have a nerve that runs down on the bottom of the foot and actually goes right across this area. So there’s a nerve that splits like this. It goes right through here. Now that nerve actually is called the deep perineal nerve. It comes over the top of the foot and then it dives down deep like that. And so all of these things are crossing both here and at this level on the bottom of the foot, in between the toes, right where all of his pain is. And so he realized that if he pushed on the top of his foot here, that right up on the top of a foot up in this area, where there was a bony prominence pushing up, if he pushed down there, he got some weird sensations that were causing discomfort.
What do you do about this? Well, the callus here signifies that he has a lot of motion in that area in the foot right next to where the plantar plate ligament is, which may mean that the first metatarsal is moving out of the way and it’s creating a lot of pressure on the plantar plate ligament and causing a plantar plate sprain. Well, the reason you need to know that is that also he is having a lot of pain in this area that he described as tingling or numbness or some weird sensations that are consistent with nerve type injury. And so if you have irritation on the top of the foot because the laces were too tight or you got some new shoes that had laces that were really rigid and they put a lot of pressure on the nerve on the top of the foot, then you can start getting pain that is referred pain on the bottom that seems like a plantar plate injury, but it’s really a nerve problem. And if you can just do something to calm down that nerve, then the pain can go away.
But in his case I said, “Well look, you have an MRI that says you have injuries to two, three, and four. I haven’t seen anybody that has true plantar plate sprains to two, three, and four. Even if the MRI says you have some fraying or some irregularity or some thickening or something like that, I just don’t buy it.” I just don’t really ever see it. I think it’s a myth. I think it’s things that radiologists put in the report to comment on that we should be aware of them and see if it correlates with the symptoms. But the problem is, when you get an MRI report, a lot of times you start thinking that, that is actually the problem and the nerves don’t show up. So the nerves aren’t going to be the problem if it’s just a little irritated on the top of your foot. And when you say the pain’s down on the bottom, they’re not going to look up there anyway. So you have to really think about what the issue is here and then try to rule that out.
What I did was I gave him some strategies to reduce the irritation of that nerve and I was just saying, “Look, you’ve got to figure this out. You’ve got to track your pain. You have to think about your pain numbers. You have to see how much of your nerve discomfort goes away when you’re only addressing the nerve up on the top of the foot. And if all of your pain starts dissipating very rapidly on the bottom of the foot but you’re not actually treating that part per se, then you know that you don’t have a plantar plate injury that needs surgery or a PRP injection or anything fancy. You just have to get the nerve to calm down. You’ve got to decrease the pressure on the nerve on the top of the foot, continue to get that nerve to quiet down, and then if your pain really does start to dissipate, you don’t have to worry as much about the plantar plate injury.
But the fact that there is this callus here, you’ve got to address that too, because I will tell you that if you have a big, thick callus, a ridge like that, that actually creates a pressure point that’s pushing into the bottom of the foot, that can aggravate both the nerve and the plantar plate and the joint capsule and the structures on the bottom of the foot.
If you get a big, huge callus, you need to keep that shaved down as well. You don’t want to take all of it off because then you’ll get a blister, but you should take off a lot of that callus to stop that pressure too. But this just shows you that sometimes when you get an MRI and you’re told you have something like a plantar plate, you really have to think about the symptoms and look at the foot and figure out, does it really make sense given all the other things you see because the callus could cause a problem, the nerve could cause a problem, and it’s not just the plantar plate that happens to show up on the MRI. By the way, the callus, not on the MRI.
So think about the details, really think about your story, and when you go in to see your doctor, make sure you discuss all of these things together so that you can get the right opinion for you and you can get back to running as quickly as possible.
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