What is the worst possible medical imaging study you could get if you’re a runner with a suspected plantar plate injury? Well, that’s what we’re talking about today on the Doc On The Run Podcast.
If you’re a runner and you start having pain in the ball of the foot particularly at the base of the second toe. You probably might start researching it and then become concerned you have a thing called a plantar plate injury. I think it’s helpful to understand briefly what this is and which studies may help you, which ones may not and which one is the biggest waste of time.
When you look at the bottom of the foot and you’re looking at the base of the second toe, that’s where most people who get a plantar plate injury are having trouble. That’s why when you start researching and you start having pain, right here at the base of the toe in this area, we suspect plantar plate injury. When you look at it in the from a side view, where we’re looking at cross section of your foot kind of through that second metatarsal bone area like this. That’s a terrible metatarsal but you get the idea. You got three little bones in the toe. The plantar plate ligament is a thickening of this joint capsule, basically right on the bottom of the foot. So, the pain is here, right there.
The thing is, is when we get X rays, and the doctor says “Oh, you have pain on your foot, let’s do some X-rays . Let’s see if we see anything.” Well, what would they be looking for? Well, maybe a broken bone. So very unlikely to break this. I’ve only seen this one time where somebody had pain in the exact same spot you would get with a plantar plate injury, but actually had a chip have the metatarsal fracture. I’ll probably do another episode on that. But I’ve only seen it once.
So in all of these years, more than 20 years of seeing patients, I have only seen in one time. So as the saying goes if you’re in Texas and you hear “Hoofbeats don’t go looking for zebras” and doing an X-ray to look for a fracture when your pain is right here in the spot you have a plantar plate injury is definitely looking for zebras.
There is some credence to the idea that you can see trouble that suggests a plantar plate injury like if this is the metatarsal bone and the proximal phalanx bone is supposed to be sitting right here. But when the doctor does an X-ray and looks at the side view, what she sees is that the metatarsal bone is sitting up here. Well, the bone has moved up it’s out of position and so what that means is that the plantar plate ligament that should be here is actually ripped and the toe is drifting upward because the ligament is no longer intact.
However, you don’t need an X-ray to see that the toes not sitting in the right position, it’s sitting up. It’s moved. It’s different. It’s in the wrong position. Another is that the toe could be deviated. So instead of sitting like on this view, the AP X-ray view, if we look at the second metatarsal and something changes and it could suggest trouble. So, if the bone is sitting like this here, then all of this stuff has to be intact.
But if the bone is suddenly sitting over here then what that usually means is that the collateral ligaments over here have ripped because the toe has deviated over. But again, you don’t need an X-ray to see that. You look at the foot and the toes is crooked, you don’t need an X-ray to see that and I wouldn’t get one. So, the X-ray is actually the most useless test and probably most overdone test when somebody has pain in this particular spot and is suspected of having a plantar plate sprain.
If you think you have a plantar plate sprain and you call me, I would actually work you through some specific things to try to figure it out on your own without even ordering X-rays. If you had some weird circumstance that might be like that one guy that had a chip fracture. Well, I was suspicious of that. I did a consultation call with him, and I ordered X-ray sand he got X-rays and we looked at him together. And sure enough, he had a fracture we could see on the X-ray but in that case, it was unusual.
So, if you had an unusual thing and I thought it might be helpful for you to get X-rays, well I would order them for you and then we would look at them together online over webcam so you can see what’s going on. But I think that most of the time when we go into the doctor, the doctor says “Oh no, your foot hurts. Let’s just get some X rays.” They charge you for the X-rays and bill your insurance and they get paid for it. But I think it’s a big waste of time and I truthfully don’t think you need any extra radiation unless we really think you have an injury that warrants the cost and the exposure to the radiation.
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