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In conclusion PPTs commonly occur and as illustrated by this case study can be successfully identified by simple clinical tests and ultrasound. Concomitant interspace lesions can also be characterized. The ability to accurately differentiate between a tear and Morton’s neuroma is particularly advantageous as it indicates the correct treatment option and avoids the inappropriate administration of a steroid injection when the pathology is a tear. 1. Umans, H., Srinivasan, R., Elsinger, E. & Wilde, G. (2014) 'MRI of lesser metatarsophalangeal joint plantar plate tears and associated adjacent interspace lesions', Skeletal Radiology; Journal of the International Skeletal Society A Journal of Radiology, Pathology and Orthopedics, 43 (10), pp.1361-1368. 2. Fernandes, E.d.A., Mann, T.S., Puchnick, A., Tertulino, F.d.F., Cannato, C.T., Nery, C. & Fernandes, A.d.R.C. (2014) 'Can ultrasound of plantar plate have normal appearance with a positive drawer test?', European Journal of Radiology, 84 (3), pp.443-449. 3. Yao, L., Do, H.M., Cracchiolo, A. & Farahani, K. (1994) 'Plantar plate of the foot: findings on conventional arthrography and MR imaging' American Journal of Roentgenology, 163 pp.641-644. 4. Baravarian, B. & Redkar, A. (2016) 'Expert Insights On Treating Plantar Plate Tears Available at: http://www.podiatrytoday.com/expert-insights-treating-plantar-plate- tears (Accessed: 27/10/2016) 5. Thompson, F. & Hamilton, W. (1987) 'Problems of the Second Metatarsophalangeal Joint', Orthopedics, 10 (1), pp.83-89. 6. Doty, J., Coughlin, M., Jastifer, J., Weil, L. & Nery, C. (2014) 'Evaluation and Treatment of Lesser Metatarsophalangeal Joint Instability: The Repair of Plantar Plate Insufficiency Through a Dorsal Approach', Operative Techniques in Sports Medicine, 22 (4), pp.339-347. 7. Bouché, R.T. & Heit, E.J. (2008) 'Combined Plantar Plate and Hammertoe Repair with Flexor Digitorum Longus Tendon Transfer for Chronic, Severe Sagittal Plane Instability of the Lesser Metatarsophalangeal Joints: Preliminary Observations', The Journal of Foot and Ankle Surgery, 47 (2), pp.125-137 8. Gregg, J., Silberstein, M., Schneider, T., Kerr, J. & Marks, P. (2006a) 'Sonography of plantar plates in cadavers: correlation with MRI and histology', American Journal of Roentgenology, 186 pp.948-955. 9. Bianchi, S. (2014) 'Practical US of the forefoot', Journal of Ultrasound; the Official Journal of the Italian Society for Ultrasound in Medicine and Biology, 17 (2), pp.151-164. 10. Macias, D. & Coughin, M. (2015) 'Lesser metatarsophalangeal joint instability: Diagnosis and treatment of plantar plate tears', Orthopedics Today, 35 (10), pp. 14-17. 11. Gregg, J., Silberstein, M., Schneider, T. & Marks, P. (2006b) 'Sonographic and MRI evaluation of the plantar plate: a prospective study', European Radiology, 16 (12), pp.2661-2669. 12. Klein, E.E., Weil Jr, L., Weil Sr, L.S. & Knight, J. (2013) 'Musculoskeletal Ultrasound for Preoperative Imaging of the Plantar Pate A prospective Analysis', Foot & Ankle Specialist, 6 (3), pp.196-200 13. Carlson, R.M., Dux, K. & Stuck, R.M. (2013) 'Ultrasound Imaging for Diagnosis of Plantar Plate Ruptures of the Lesser Metatarsophalangeal Joints: A Retrospective Case Series', The Journal of Foot & Ankle Surgery, 52 (6), pp.786-788. 14. Klein, E.E., Weil Jr, L., Weil Sr, L.S. & Knight, J. (2012) 'Magnetic resonance imaging versus musculoskeletal ultrasound for identification and localization of plantar plate tears', Foot & Ankle Specialist, 5 (6), pp.359-365 15. Ganguly, A., Aniq, H. & Skiadas, B. (2013) 'Lumps and bumps around the foot and ankle: an assessment of frequency with ultrasound and MRI', Skeletal Radiology; Journal of the International Skeletal Society A Journal of Radiology, Pathology and Orthopedics, 42 (8), pp.1051-1060. 16. Khoury, V., Guillin, R., Dhanju, J.& Cardinal, E. (2007) 'Ultrasound of Ankle and Foot: Overuse and Sports Injuries', Seminars in Musculoskeletal Radiology 2007, 11 (02), pp.149-161. Case study Discussion A 66 year old female with metatarsalgia in the region of the left 2 nd toe was referred by an MSK podiatrist for ultrasound assessment of the pain. A steroid injection was also requested to be performed at the time of the scan if a Morton’s neuroma was detected. A brief clinical examination of the affected toe was performed before the scan. The patient was first observed with the foot uncovered, in the standing position, to assess for medial toe drift. Clinical tests for a PPT were then undertaken to assess for any reduced plantar purchase and/or a positive metatarsophalangeal ‘drawer test’ (See clinical tests below). The foot was also assessed for a Mulder click by using sonopalpation and simultaneously squeezing the forefoot. The left forefoot was then scanned on a Philips iu22 machine using a 17MHz linear transducer with a musculoskeletal preset. Longitudinal and transverse assessment was made of the 2 nd MTPJ, the plantar plate and the adjoining toe interspaces. Colour Doppler was then applied to assess for abnormal vascularity within the joint and/or interspaces. There is nothing in the literature to suggest guidelines or a definite consensus on imaging of suspected PPTs; that said there is a general trend towards MRI as the preferred non-invasive imaging modality (10). The first studies to evaluate PPTs with ultrasound were conducted by Gregg et al in 2006 (8, 11) and showed slightly better detection rates compared with MRI. Later studies indicated that although ultrasound had excellent sensitivity, the specificity is lower than MRI, and it gives less accurate localization (12, 13). MRI is also better at detecting soft tissue pathology around the joint such as co-lateral ligament tears (14). Ultrasound is however better at detecting interspace lesions such as ganglions, neuromas (15) and inter-metatarsal bursitis (16). These studies indicate that ultrasound is more sensitive than MRI in detecting plantar plate tears and this, together with its low-cost and flexibility, suggest that ultrasound is suitable as the first line test. As they also show that ultrasound has a poorer specificity than MRI, this might suggest that ultrasound alone may not suffice for surgical planning, and in some cases follow-up MRI imaging may be required. Clinical assessment is commonplace in forefoot imaging (9) and the specific tests for MTPJ stability described here are especially useful in assisting detection of a PPT in combination with ultrasound, as in this case study. However it should be noted that the plantar plate presents challenges for both MRI and ultrasound scanning as it is a small curved structure which can be difficult to access with an MRI coil, and susceptible to anistropy with ultrasound (8). In addition, some tears are not easily visualised on ultrasound as hypoechoic areas, as there can be an infill of loose connective tissue as repair commences (8). Paper pull-out test' This second test measures plantar flexion strength and was first described by Bouché and Heit (7). A strip of paper (1 x 6cm) is placed beneath the tip of the affected toe and the patient is asked to perform plantar flexion of the forefoot, and to press down on the paper with the toe. (See photograph). The test is positive when the digit is unable to grip the paper and the strip can be pulled out without ripping. Findings from this test have been combined with the 'Drawer test' to provide clinical staging (6). Another sign of a plantar plate tear is medial toe drift which presents because the tear occurs most commonly on the lateral edge, allowing the flexor tendon to pull the toe medially. This is best observed with the patient standing at the start of the ultrasound examination (as demonstrated in the case study findings). Clinical test for plantar plate tears There are two recognized clinical tests for PPTs, the metatarsophalangeal 'drawer test' and the 'paper pull out test'. Metatarsophalangeal 'drawer test' Devised by Thompson and Hamilton (5), the 'drawer test' of the MTPJ is designed to test joint stability, and according to Doty et al (2014) (6) has 80.6% sensitivity and 99.8% specificity for PPT. The toe has vertical stress applied in a dorsal direction and the amount of subluxation and pain produced by the test can be graded 1-4 (see figure below). GO, stable joints G1, mild instability (subluxation <50%); G2, moderate instability (subluxation <50%); G3, severe instability (capacity for joint dislocation) G4, dislocated joint References Clinical and scan findings A physical examination of the foot identified swelling of the 2 nd MTPJ as well as medial toe drift, which the patient confirmed was a recent development. The paper pull out test and drawer test were both positive. No Mulder click was identified. The scan confirmed the presence of a partial, laterally located plantar plate tear. Osteophytes within the MTPJ and a probable MTPJ ganglion were also identified. There was no Morton's neuroma in evidence. No abnormal vascularity was noted within the joint, or in the toe interspaces either side of the 2 nd toe. Follow up A steroid injection was not performed due to the presence of a tear. The referring podiatrist opted initially for conservative treatment using strapping and orthotics, and follow up after one month indicated an improvement in symptoms. 2. TS section of the plantar plate 1. LS section of 2 nd toe plantar plate 4. TS section demonstrating cystic mass 3. TS section of the plantar plate Photo by Angela Clough Diagram by Angela Clough Diagram by Angela Clough Photo by Angela Clough Figure by kind permission of Doty et al Diagram of LS section of plantar aspect of MTPJ U/S image of LS section of plantar aspect of MTPJ Diagram of TS section of plantar aspect of MTPJ Plantar plate tears (PPTs) are a common but sometimes overlooked cause of forefoot pain, as shown in a 2014 study which identified that 40% of patients with metatarsalgia had detectable PPTs (1). Ultrasound has a valuable role in diagnosing PPTs and is most effective when combined with simple clinical tests at the time of the examination, as demonstrated in this case study. The plantar plate is a fibrocartilaginous structure which stabilizes the plantar aspect of the metatarsophalangeal joint (MTPJ). It prevents dorsi-extension of the toe and is part of a complex of support structures for the MTPJ as seen in the LS and TS sections below The plantar plate is susceptible to partial or complete tears due to chronic overload, age or trauma. Tears typically present with burning, throbbing or tingling and are commonly misdiagnosed as a Morton’s neuroma, stress fracture or arthropathy. The second MTPJ is most commonly affected as it has the longest metatarsal bone (2). The incidence of metatarsalgia relating to symptomatic PPTs may be explained by associated pathology such as capsular inflammation which can occur secondary to a tear, as described in an early study in 1994 by Yao et al (3). A more recent MRI study in 2014 (1) looking at adjacent interspace lesions in patients with PPTs, found that a significant number of symptomatic second toe PPTs had coexisting non-neuromatous second interspace lesions. The most common pathology identified was peri-capsular fibrosis followed by inter-metatarsal bursitis and ganglions, and interestingly, no concomitant second interspace Morton's neuromas were detected. Treatments of PPTs include the use of strapping and/or orthotics to stabilise and off-load the joint, and non-steroidal anti-inflammatory medication when inflammation is present (4). Steroid injection is not recommended as this can further weaken or rupture the plantar plate, and this makes differentiation between plantar plate tears and a Morton’s neuroma particularly important as this is a common treatment for the latter (4). The plantar plate does not readily repair itself as it is made of type 1 collagen, and where conservative treatment has been exhausted, surgery may be required to achieve satisfactory MTPJ alignment, stability and pain reduction (1). 3 Ultrasound assessment of a common cause of forefoot pain: Plantar plate tear of the 2 nd -5 th metatarsophalangeal joint Angela Clough - Advanced Practitioner Sonographer Photos of patient’s foot demonstrating medial drift of the 2 nd toe Acknowledgement: I would like to thank Dr Peter G Stoddart for his continued support and training whilst at Weston General Hospital Clinical and scan findings Introduction

PPT poster 3 - BMUS · 2018. 10. 26. · Plantar plate tears (PPTs) are a common but sometimes overlooked cause of forefoot pain, as shown in a 2014 study which identified that 40%

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Page 1: PPT poster 3 - BMUS · 2018. 10. 26. · Plantar plate tears (PPTs) are a common but sometimes overlooked cause of forefoot pain, as shown in a 2014 study which identified that 40%

InconclusionPPTscommonlyoccurandasillustratedbythiscasestudycanbesuccessfullyidentifiedbysimpleclinicaltestsandultrasound.Concomitantinterspacelesionscanalsobecharacterized.TheabilitytoaccuratelydifferentiatebetweenatearandMorton’sneuromaisparticularlyadvantageousasitindicatesthecorrecttreatmentoptionandavoidstheinappropriateadministrationofasteroidinjectionwhenthepathologyisatear.

1.Umans,H.,Srinivasan,R.,Elsinger,E.&Wilde,G.(2014)'MRIoflessermetatarsophalangealjointplantarplatetearsandassociatedadjacentinterspacelesions',SkeletalRadiology;JournaloftheInternationalSkeletalSocietyAJournalofRadiology,PathologyandOrthopedics,43(10),pp.1361-1368.2.Fernandes,E.d.A.,Mann,T.S.,Puchnick,A.,Tertulino,F.d.F.,Cannato,C.T.,Nery,C.&Fernandes,A.d.R.C.(2014)'Canultrasoundofplantarplatehavenormalappearancewithapositivedrawertest?',EuropeanJournalofRadiology,84(3),pp.443-449.3.Yao,L.,Do,H.M.,Cracchiolo,A.&Farahani,K.(1994)'Plantarplateofthefoot:findingsonconventionalarthrographyandMRimaging'AmericanJournalofRoentgenology,163pp.641-644.4.Baravarian,B.&Redkar,A.(2016)'ExpertInsightsOnTreatingPlantarPlateTearsAvailableat:http://www.podiatrytoday.com/expert-insights-treating-plantar-plate-tears(Accessed:27/10/2016)5.Thompson,F.&Hamilton,W.(1987)'ProblemsoftheSecondMetatarsophalangealJoint',Orthopedics,10(1),pp.83-89.6.Doty,J.,Coughlin,M.,Jastifer,J.,Weil,L.&Nery,C.(2014)'EvaluationandTreatmentofLesserMetatarsophalangealJointInstability:TheRepairofPlantarPlateInsufficiencyThroughaDorsalApproach',OperativeTechniquesinSportsMedicine,22(4),pp.339-347.7.Bouché,R.T.&Heit,E.J.(2008)'CombinedPlantarPlateandHammertoeRepairwithFlexorDigitorumLongusTendonTransferforChronic,SevereSagittalPlaneInstabilityoftheLesserMetatarsophalangealJoints:PreliminaryObservations',TheJournalofFootandAnkleSurgery,47(2),pp.125-1378.Gregg,J.,Silberstein,M.,Schneider,T.,Kerr,J.&Marks,P.(2006a)'Sonographyofplantarplatesincadavers: correlationwithMRIandhistology',AmericanJournalofRoentgenology,186pp.948-955.9.Bianchi,S.(2014)'PracticalUSoftheforefoot',JournalofUltrasound;theOfficialJournaloftheItalianSocietyforUltrasoundinMedicineandBiology,17(2),pp.151-164.

10.Macias,D.&Coughin,M.(2015)'Lessermetatarsophalangealjointinstability:Diagnosisandtreatmentofplantarplatetears',OrthopedicsToday,35(10),pp.14-17.11.Gregg,J.,Silberstein,M.,Schneider,T.&Marks,P.(2006b)'SonographicandMRIevaluationoftheplantarplate:aprospectivestudy',EuropeanRadiology,16(12),pp.2661-2669.12.Klein,E.E.,WeilJr,L.,WeilSr,L.S.&Knight,J.(2013)'MusculoskeletalUltrasoundforPreoperativeImagingofthePlantarPateAprospectiveAnalysis',Foot&AnkleSpecialist,6(3),pp.196-20013.Carlson,R.M.,Dux,K.&Stuck,R.M.(2013)'UltrasoundImagingforDiagnosisofPlantarPlateRupturesoftheLesserMetatarsophalangealJoints:ARetrospectiveCaseSeries',TheJournalofFoot&AnkleSurgery,52(6),pp.786-788.14.Klein,E.E.,WeilJr,L.,WeilSr,L.S.&Knight,J.(2012)'Magneticresonanceimagingversusmusculoskeletalultrasoundforidentificationandlocalizationofplantarplatetears',Foot&AnkleSpecialist,5(6),pp.359-36515.Ganguly,A.,Aniq,H.&Skiadas,B.(2013)'Lumpsandbumpsaroundthefootandankle:anassessmentoffrequencywithultrasoundandMRI',SkeletalRadiology;JournaloftheInternationalSkeletalSocietyAJournalofRadiology,PathologyandOrthopedics,42(8),pp.1051-1060.16.Khoury,V.,Guillin,R.,Dhanju,J.&Cardinal,E.(2007)'UltrasoundofAnkleandFoot: OveruseandSportsInjuries',SeminarsinMusculoskeletalRadiology2007,11(02),pp.149-161.

CasestudyDiscussion

A66yearoldfemalewithmetatarsalgiaintheregionoftheleft2nd toewasreferredbyanMSKpodiatristforultrasoundassessmentofthepain.AsteroidinjectionwasalsorequestedtobeperformedatthetimeofthescanifaMorton’sneuromawasdetected.

Abriefclinicalexaminationoftheaffectedtoewasperformedbeforethescan.Thepatientwasfirstobservedwiththefootuncovered,inthestandingposition,toassessformedialtoedrift.Clinicaltestsfora PPTwerethenundertakentoassessforanyreducedplantarpurchaseand/orapositivemetatarsophalangeal‘drawertest’(Seeclinicaltestsbelow).ThefootwasalsoassessedforaMulderclickbyusingsonopalpation andsimultaneouslysqueezingtheforefoot.

TheleftforefootwasthenscannedonaPhilipsiu22machineusinga17MHzlineartransducerwithamusculoskeletalpreset.Longitudinalandtransverseassessmentwasmadeofthe2nd MTPJ,theplantarplateandtheadjoiningtoeinterspaces.Colour Dopplerwasthenappliedtoassessforabnormalvascularitywithinthejointand/orinterspaces.

ThereisnothingintheliteraturetosuggestguidelinesoradefiniteconsensusonimagingofsuspectedPPTs;thatsaidthereisageneraltrendtowardsMRIasthepreferrednon-invasiveimagingmodality(10). ThefirststudiestoevaluatePPTswithultrasoundwereconductedbyGreggetalin2006(8,11)andshowedslightlybetterdetectionratescomparedwithMRI.Laterstudiesindicatedthatalthoughultrasoundhadexcellentsensitivity,thespecificityislowerthanMRI,anditgiveslessaccuratelocalization(12,13).MRIisalsobetteratdetectingsofttissuepathologyaroundthejointsuchasco-lateralligamenttears(14).Ultrasoundishoweverbetteratdetectinginterspacelesionssuchasganglions,neuromas(15)andinter-metatarsalbursitis(16).

ThesestudiesindicatethatultrasoundismoresensitivethanMRIindetectingplantarplatetearsandthis,togetherwithitslow-costandflexibility,suggestthatultrasoundissuitableasthefirstlinetest.AstheyalsoshowthatultrasoundhasapoorerspecificitythanMRI,thismightsuggestthatultrasoundalonemaynotsufficeforsurgicalplanning,andinsomecasesfollow-upMRIimagingmayberequired.

Clinicalassessmentiscommonplaceinforefootimaging(9)andthespecifictestsforMTPJstabilitydescribedhereareespeciallyusefulinassistingdetectionofaPPTincombinationwithultrasound,asinthiscasestudy.HoweveritshouldbenotedthattheplantarplatepresentschallengesforbothMRIandultrasoundscanningasitisasmallcurvedstructurewhichcanbedifficulttoaccesswithanMRIcoil,andsusceptibletoanistropy withultrasound(8).Inaddition,sometearsarenoteasilyvisualised onultrasoundashypoechoicareas,astherecanbeaninfilloflooseconnectivetissueasrepaircommences(8).

Paperpull-outtest'ThissecondtestmeasuresplantarflexionstrengthandwasfirstdescribedbyBouché andHeit (7).Astripofpaper(1x6cm)isplacedbeneaththetipoftheaffectedtoeandthepatientisaskedtoperformplantarflexionoftheforefoot,andtopressdownonthepaperwiththetoe.(Seephotograph). Thetestispositivewhenthedigitisunabletogripthepaperandthestripcanbepulledoutwithoutripping. Findingsfromthistesthavebeencombinedwiththe'Drawertest'toprovideclinicalstaging(6).

Anothersignofaplantarplatetearismedialtoedriftwhichpresentsbecausethetearoccursmostcommonlyonthelateraledge,allowingtheflexortendontopullthetoemedially.Thisisbestobservedwiththepatientstandingatthestartoftheultrasoundexamination(asdemonstratedinthecasestudyfindings).

ClinicaltestforplantarplatetearsTherearetworecognizedclinicaltestsforPPTs,themetatarsophalangeal'drawertest'andthe'paperpullouttest'.

Metatarsophalangeal'drawertest'DevisedbyThompsonandHamilton(5),the'drawertest'oftheMTPJisdesignedtotestjointstability,andaccordingtoDotyetal(2014)(6)has 80.6%sensitivityand99.8%specificityforPPT. Thetoehasverticalstressappliedinadorsaldirectionandtheamountofsubluxationandpainproducedbythetestcanbegraded1-4 (seefigurebelow).

GO,stablejointsG1,mildinstability(subluxation<50%);G2,moderateinstability(subluxation<50%);G3,severeinstability(capacityforjointdislocation)G4,dislocatedjoint

References

ClinicalandscanfindingsAphysicalexaminationofthefootidentifiedswellingofthe2nd MTPJaswellasmedialtoedrift,whichthepatientconfirmedwasarecentdevelopment.Thepaperpullouttestanddrawertestwerebothpositive.NoMulderclickwasidentified.

Thescanconfirmedthepresenceofapartial,laterallylocatedplantarplatetear. OsteophyteswithintheMTPJandaprobableMTPJganglionwerealsoidentified.TherewasnoMorton'sneuromainevidence. Noabnormalvascularitywasnotedwithinthejoint,orinthetoeinterspaceseithersideofthe2nd toe.

Followup

Asteroidinjectionwasnotperformedduetothepresenceofatear.

Thereferringpodiatristoptedinitiallyforconservativetreatmentusingstrappingandorthotics,andfollowupafteronemonthindicatedanimprovementinsymptoms.

2.TSsectionoftheplantarplate1.LSsectionof2nd toeplantarplate

4.TSsectiondemonstratingcysticmass3.TSsectionoftheplantarplate

PhotobyAngelaClough

DiagrambyAngelaCloughDiagrambyAngelaClough

PhotobyAngelaClough

FigurebykindpermissionofDotyetal

DiagramofLSsectionofplantaraspectofMTPJ U/SimageofLSsectionofplantaraspectofMTPJ DiagramofTSsectionofplantaraspectofMTPJ

Plantarplatetears(PPTs)areacommonbutsometimesoverlookedcauseofforefootpain,asshownina2014studywhichidentifiedthat40%ofpatientswithmetatarsalgiahaddetectablePPTs(1).UltrasoundhasavaluableroleindiagnosingPPTsandismosteffectivewhencombinedwithsimpleclinicaltestsatthetimeoftheexamination,asdemonstratedinthiscasestudy.

Theplantarplateisafibrocartilaginousstructurewhichstabilizestheplantaraspectofthemetatarsophalangealjoint(MTPJ).Itpreventsdorsi-extensionofthetoeandispartofacomplexofsupportstructuresfortheMTPJasseenintheLSandTSsectionsbelow

Theplantarplateissusceptibletopartialorcompletetearsduetochronicoverload,ageortrauma.Tearstypicallypresentwithburning,throbbingortinglingandarecommonlymisdiagnosedasaMorton’sneuroma,stressfractureorarthropathy. ThesecondMTPJismostcommonlyaffectedasithasthelongestmetatarsalbone(2).

TheincidenceofmetatarsalgiarelatingtosymptomaticPPTsmaybeexplainedbyassociatedpathologysuchascapsularinflammationwhichcanoccursecondarytoatear,asdescribedinanearlystudyin1994byYaoetal(3). AmorerecentMRIstudyin2014(1)lookingatadjacentinterspacelesionsinpatientswithPPTs,foundthatasignificantnumberofsymptomaticsecondtoePPTshadcoexistingnon-neuromatous secondinterspacelesions. Themostcommonpathologyidentifiedwasperi-capsularfibrosisfollowedbyinter-metatarsalbursitisandganglions,andinterestingly,noconcomitantsecondinterspaceMorton'sneuromasweredetected.

TreatmentsofPPTsincludetheuseofstrappingand/ororthoticstostabilise andoff-loadthejoint,andnon-steroidalanti-inflammatorymedicationwheninflammationispresent(4). Steroidinjectionisnotrecommendedasthiscanfurtherweakenorrupturetheplantarplate,andthismakesdifferentiationbetweenplantarplatetearsandaMorton’sneuromaparticularlyimportantasthisisacommontreatmentforthelatter (4).

Theplantarplatedoesnotreadilyrepairitselfasitismadeoftype1collagen,andwhereconservativetreatmenthasbeenexhausted,surgerymayberequiredtoachievesatisfactoryMTPJalignment,stabilityandpainreduction(1).

3 Ultrasound assessment of a common cause of forefoot pain: Plantar plate tear of the 2nd-5thmetatarsophalangeal joint

Angela Clough - Advanced Practitioner Sonographer

Photosofpatient’sfootdemonstratingmedialdriftofthe2nd toe

Acknowledgement:IwouldliketothankDr PeterGStoddart forhiscontinuedsupportandtrainingwhilstatWestonGeneralHospital

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BMus (01132003) - UP

BMus (01132003) - UP

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Philip McKinney, DPM Oregon Podiatry Clinic Eugene, Oregon · Interdigital Neuroma Pain to the plantar aspect of the forefoot Area of pain at location near distal metatarsal heads

Philip McKinney, DPM Oregon Podiatry Clinic Eugene, Oregon · Interdigital Neuroma Pain to the plantar aspect of the forefoot Area of pain at location near distal metatarsal heads

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Mid-term functional outcome of a total arthroplasty of the ...12 plantar pressure and peak force in the forefoot increase, especially in the medial forefoot and 13 hallux. The second

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Treatment for plantar fasciitis how to heal plantar fasciitis, foot plantar fasciitis

Treatment for plantar fasciitis how to heal plantar fasciitis, foot plantar fasciitis

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