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399 Views 1 Reply Latest reply: May 1, 2014 6:47 AM by JamesJohnsonLMT
Sweetmeat72 Rookie 4 posts since
May 15, 2011
Currently Being Moderated

Apr 27, 2014 11:10 AM

Plantar plate tear

About 2 years ago (summer 2012) I was near the end of my run and felt something very painful in my foot.  I tried to finish my run but was only able to run for about a half block until the pain was just too much to bear.  I ended up limping home and completely stopped running.  I waited a couple of days before seeing a doctor as I was hoping the pain was temporary and would just go away.  The first Dr I saw diagnosis was pre-dislocation syndrome.  He prescribed a steroid pack and some anti-inflammatories which did wonders within just the first few days.  My pain went from a 9 to a 2.  He also said I should be able to get back to running pain free in 3 months.

 

I waited the entire 3 month period before trying to run again.  Walking I felt fine most of the time, but as soon as I started running the pain would return, although not nearly at the same level as it was initially.  Since I still had pain, I knew it hadn't completely healed and didn't try to continue running.  I waited 3 more months and tried running again with the same results, so I went to see a second Dr.  This Dr's diagnoses was hammer toe and had me tape my big toe and 2nd toe together for a couple of weeks, along with daily icing, and taking anti-inflammatories and putting a metatarsal pad on an insole I purchased from a running store.  2 weeks later I felt better walking, but still felt pain when I tried to run.  I decided to wait a bit longer and see if things would improve naturally. 

 

At the beginning of this year I thought maybe the injury had healed.  I bought a Landice treadmill with an ortho belt and tried running at home.  I ran for a few days, but the pain kept coming back.  I decided it was time for a permanent fix and scheduled an appointment with a 3rd Dr (I moved to a new state after seeing the 2nd Dr).  The 3rd Dr's diagnosis was a plantar plate tear and would need an osteotomy (shortening of 2nd toe bone).  The Dr's office setup surgery for April 24 at one of the local hospitals.

 

I called each place to get an estimate of fees, and was told the outpatient hospital facilities charge would be $15,000, surgeons fees would be around $3,000 and the anesthesiologist's fees would be $750.  These amounts were the contracted rates with my insurance company - United Health Care.  The surgery was to take about 1 hour, and require around 30 minutes in the recovery room. 

 

When the hospital told me $15,000, I wanted to reach through the phone and slap them.  I couldn't even believe they could actually say that with a straight face.  I ended up calling my Dr's office and asked if they do surgeries anywhere else, and they told me about some surgery clinic.  I called them and was told the fees would be $3,300 for the exact same procedure.  Needless to say, I decided on going to the surgery clinic. 

 

As a side note, the surgery clinic was connected to the hospital that wanted to charge $15,000, and many of the workers were from the hospital.  My wife works at that hospital and ran into many people she has worked with.  Absolutely insane that they'd charge 5 times the amount as the surgery clinic, with using the same employees. 

 

So I showed up for my surgery on the 24th at 8:00, surgery was at 9:00, and I was back in my car at 11:00 am.  A total of 3 hours, with a full hour being check in time and prepping for surgery.  Really, the hospital wanted to charge $5,000 PER HOUR?  Again, absolutely insane.  Make sure you know the facilities charges before you go in for any surgery of this type.

 

After the surgery, the doctor said everything was what he expected, and my tendon was barely hanging on.  I've read where other people have received a grade rating of their tear, but my Dr did not tell me the grade.

 

After surgery I went home and sat in my chair with a big footrest, and propped my foot up with about 6 pillows and applying ice often. The first day I was anticipating a lot of pain, so I was regularly taking the hydrocodone at the prescribed times.  I never really felt much pain even now, 3 days after surgery, and not taking meds.  Walking with the boot has been extremely difficult and painful, although today seems much better.

 

The Dr said that I should be able to run for 3 miles in 3 months, so I'm hoping that actually happens.

 

Anyway, just thought I would share my experience, and I hope it helps out someone who also has the debilitating injury.  It has been extreme long, much much longer than I was originally told it would before I could run again (3 months), but now I'm hopeful after surgery I really can get back to it and lose some of the pounds I've put on while not running.

  • JamesJohnsonLMT Legend 1,167 posts since
    Aug 23, 2009
    Currently Being Moderated
    1. May 1, 2014 6:47 AM (in response to Sweetmeat72)
    Re: Plantar plate tear

    I'm going to guess that you were wearing motion-control shoes that kept your foot from rolling normally into pronation. You may have tried minimalist shoes that allowed too much dorsiflexion of the toes, or some combination of the two. I'm also going to guess that your 1st metatarsal is shorter than the 2nd, but they decided to cut your 2nd toe down, which is a heck of a lot easier than lengthening the 1st metatarsal. I'm hoping that you did not just plunge into running without leading up to it gradually, but this is often not the case with new runners.

     

    I'm sorry to hear of your condition, and even more disappointed that a basic biomechanical issue was reduced to symptom relief by your doctors. Every specialist seems to see part of the problem without putting the whole picture together. Efficient, sustainable running requires sound biomechanics to avoid injury. There are many ways to bring about better biomechanics, but cutting away problem areas is, to me, not a solution, just a temporary work-around to avoid the consequences of bad biomechanics.

     

    The doctors are correct that differences in bone length directly affect foot health in active individuals. Look down at your foot, and you will see a clear difference in thickness between the 1st and 2nd rays of your foot. Obviously, the 1st bone is designed to bear more weight than the 2nd-5th, but when it is too short, as it is in a large number of individuals, weight shifts to the longer 2nd metatarsal by default during the end of each stride when you run. Depending on how your biomechanics adapt to this stress, your symptoms may vary from excess pronation of the foot (to shift weight back to the 1st metatarsal), to excess dorsiflexion of the smaller toes, particularly the second, leading to the condition you have had.

     

    It would seem logical to conclude that the 2nd metatarsal is too long, as it appears to be by contrast with the 1st, but this logic is way too simple. With a surgically shortened 2nd, you now get to shift weight to even smaller metatarsals in a domino effect. Problems shifting weight to the stronger 1st metatarsal can be complicated by excess flexibility in the ligaments supporting it, so that the resulting biomechanics shift weight to the lesser metatarsals as a way to achieve stability at the end of the gait cycle. Since these smaller bones are not built to handle this stress, tearing of the plantar plate before destruction of the metatarsalphalangeal joint is the result. Same etiology in Frieberg's. Here's a podiatrist's discussion of the problem, with lots of input from readers. Warning: graphic pics of advanced conditions.

     

    What I found interesting, even slightly amusing, is the Dr's mention of the weight shift away from 1st to 2nd metatarsals "for some reason." That is what I am talking about regarding knowledge of biomechanics. Biomechanics 101 would start like this: Your foot is constructed in such a way that it is mechanically unstable, eg: short orhypermobile 1st metatarsal. This causes stress and pain at the 2nd metatarsal, relaying messages to the spinal cord and brain. Short-term solutions can be handled via the "reflex arc" before processing by the brain, but long-term adaptations will involve coordination by various parts of the brain. Your biomechanics have now been adjusted to shift weight away from the 2nd metatarsal. In some individuals, the change will be excess pronation. In others, the second toe will be lifted away from the injury site.

     

    Biomechanics start with proprioception, or the feedback from muscle sensation that inform the body of where things are in space. It gets refined temporarily by pain, often at the spinal level, and more permanently by the brain in response to proprioception and pain. Since biomechanics affect the general posture of the body, symptoms as remote  as headaches and other more severe neurological disorders have been laid at the feet of, well, the feet.

     

    Since weight still stays the same regardless of how the impact is redistributed by biomechanics, physical damage to the foot depends on how well-suited the location of impact is to the load presented. The lesser metatarsals are no match for the strength of the 1st metatarsal in terms of weight-bearing, so your foot loses this battle.Surgical interventions for the resulting destruction of your foot vary, but lengthening or strengthening of the primary weight-bearing 1st metatarsal are not chief among them, probably due to cost. Conventional orthotic interventions can fail in cases of hypermobility. The result is continued degradation of the foot.

     

    Over a half-century ago a Dr. Dudley Morton hypothesized that a shorter 1st metatarsal is really a link to our evolutionary past as non-running hominids. The lengthening of this 1st metatarsal, long with modifications to other structures such as fore-aft movement of the head via neck bones and the occiput, is what allowed endurance running to make homo sapiens into a successful hunting species by allowing us to stalk prey to exhaustion. Evolutionary theory would suggest that those without this successful genetic adaptation would die off, but homo sapiens as a cooperative species shares the wealth from productive hunting, allowing this incomplete formation of the foot to continue ironically in perpetuity. It is present in a high percentage of the modern population (as it is in myself), and shows no signs of disappearing anytime soon.

     

     

    So yeah, running is cool, and a sign of evolutionary success. It does not mean that all of us are born with an ideal foot for this purpose, however. I achieved success dealing with my inadequate structure by padding under my 1st metatarsal to mimic a longer one, thereby altering proprioception. I was lucky, as I got to it in time, and did not suffer from any complicating hypermobility issues in my foot structure, just a short 1st metatarsal (toes are of "normal" length). Many have benefitted from this fix, but it cannot work in all cases involving hypermobility, and needs to be applied before further pathology develops. I wish you the best of luck in your more advanced case, and would strongly advise you to consider non-impact or low-impact cross-training before any consideration of running. A return to running would not necessarily be permanent.

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