Health matters: Complex anatomy leads to deforming toe

Dr. Conway McLean, Journal columnist

The years take their toll on the human body. The pull of gravity, the pounding of the pavement, excess pounds around the middle, many factors contribute to the changes experienced by our physical selves. The first thought of many people regards the “aesthetic” alterations, the inevitable lines and sagging skin. But these are just the obvious ones, staring at us in the mirror each morning, the years adding lines like tree rings, marking the passage of time.

Many causes of chronic pain are related to our dealings with Father Time. But some other component is needed for most chronic problems to develop. Take, for example, the alignment of the knee, which varies person to person, and can increase the likelihood of knee osteoarthritis. This is also true in the foot, where a common foot type makes more probable the development of various deformities. A permutation of a hammer-toe deformity is the dreaded plantar plate tear.

Probably beneficial at this juncture is a description of what this structure looks like and what it does. It’s a tough, fibrous, rectangular soft tissue structure, to which many other items, tendons and ligaments, attach. It sits under each of the joints in the ball of the foot, acting as a fulcrum, a point of stability, for all these neighboring structures.

When the foot functions in such a way that the 2nd joint (that which is next to the big toe joint) receives physical stress, problems develop with the plantar plate, since it’s receiving all the pounding to this body part. Some plantar plate problems develop over the years, as opposed to those due to trauma or a sports injury. How much stress is largely dependent on foot structure, which is primarily inherited.

Our protagonist for this discussion is Susan, a middle-aged female, mildly overweight, employed in a very physical job. Her feet have ached in a general sense for years, but nothing specific, nothing disabling, and certainly nothing that would keep her from work. Still, the pain Susan began noticing in the ball of her left foot was getting her attention. That region had always been a problematic one, a challenging workday reliably resulting in aching pain from the area.

Over the years, the pain from the ball of her foot started earlier in the day, and became more painful at the end. Even more disturbing was the developing deformity. Her second toe was no longer touching the floor when she stood up straight. Also, the skin over the first joint of her second toe was getting increasingly irritated by pressure from her shoes. But this pain paled in comparison to that from the bottom of the foot, just behind the base of the second toe.

Like any soft tissue structure, the plantar plate initially becomes inflamed with stress. With prolonged and excessive manipulation, the plantar plate gets stretched out of position. Because of its critical importance to the stability and positioning of the digit, this elongation initiates the altered alignment of the second toe, whereby the toe lifts upward at the ball of the foot and the toe joint bends down.

Likely the most common foot type leading to plantar plate problems is one possessing an unstable first metatarsal bone. Unfortunately, this is part of many common foot types. Another frequent finding in this population is a tight Achilles tendon. The problems which can result from an overly tight Achilles are numerous, but one of them is plantar plate instability, the term used describing this slowly developing painful deformity.

When nothing is done for the conditions stressing the plantar plate, this can progress to a tear of the plate, worsening over time, as the second toe slowly drifts upward, bending at the ball of the foot. The plate itself will usually become increasingly traumatized and torn, allowing continued dislocation of the joint. As is predictable, arthritic changes to the joint will also ensue. The forces on this joint can also lead to similar problems to the third and fourth toes, but these are usually much less obvious.

Many factors are involved in the occurrence of symptoms, consequently many methods of treatment exist. Reducing inflammation will reduce the pain, which is why anti-inflammatories provide temporary relief. They do nothing for the physical forces on the structure, but reduce acute inflammatory pain. Unfortunately, these medications have been shown to initiate the conversion of acute inflammation, part of the healing process, to chronic, which is a distinct problem.

Excessive lowering of the arch in gait can greatly increase the chances of having plantar plate instability. This includes those who pronate excessively, a common finding in which, basically, the arch rolls (inward) too much. Reducing this pathologic motion can eliminate symptoms from this second joint in the ball, best achieved with prescription foot supports, usually referred to as foot orthotics. These are placed inside the shoe, in effect bringing the ground up to the foot, rather than gravity forcing the foot down to the ground, and out of proper position. Susan went this route and had great relief (although her toe still doesn’t touch the ground).

For plantar plate injuries which are less severe, various toe braces and strapping techniques can make a real difference in symptoms. Addressing the root of the problem, the individual’s biomechanics is the most fundamentally effective approach, but these answers are far from obvious. If a tight Achilles is present, stretching exercises should be prescribed and performed on a regular basis (for longer than you might think).

Various surgical procedures are utilized for plantar plate instability, from correction of the bony alignment to repair of the tear in the plantar plate. Although many surgeons have their favorite procedures, the choice should primarily depend on the specifics of the deformity and the biomechanical function leading to the condition.

As is so often the case, an accurate generalization in medicine is the sooner a problem is identified, and an appropriate course of action taken, the better the results. When you know you have a problem, like a toe moving out of position, without effective treatment, it’s probably going to get worse. Unfortunately, this leads to the next question of getting proper attention. This is a whole other challenge.


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