Plantar Plate Injuries: Understanding a Common Cause of Forefoot Pain

Pain under the ball of the foot is widespread, yet one of its most frequent causes often goes undiagnosed. The plantar plate is a small ligament that helps stabilize the toes with every step. When it becomes strained or torn, even simple walking can feel uncomfortable.

This guide explains what the plantar plate is, why it can be injured, the symptoms to look for, and the available treatment options.

What Is the Plantar Plate?

The plantar plate is a ligament on the bottom of the foot that anchors each toe to its corresponding metatarsal bone. Think of it as the stability strap that keeps your toe from drifting upward or sideways when you walk.

Its main jobs include:

• Supporting the ball (metatrsalphalangeal joint) of the foot during weight-bearing

• Preventing the toe from shifting or lifting-deviation or dislocation

• Absorbing pressure during walking and running

Because the second metatarsal head (ball of the foot) carries the most pressure, injuries most often occur at the second plantar plate.

Why Does the Plantar Plate Tear?

Most plantar plate injuries develop slowly over time due to repetitive stress and increased load, though a sudden injury can also occur.

Common causes include:

1. Excess Pressure on the Forefoot

Activities like running, long walks, lunges, or uphill climbing increase the bending force/load through the ball of the feet into the toes.

2. Foot Structure

Some people naturally have features that shift more pressure to the second toe, such as:

• A longer metatarsal/toe

• Flat feet or high arches

• A bunion that pushes the second toe out of position

3. Footwear Choices

Shoes that bend too easily, lack support, or have high heels increase strain on the ligament.

4. Age-Related Changes

Over time, the ligament can thin and weaken, making it more prone to injury.

Widely across clinical practice, these factors collectively make the plantar plate vulnerable to microtearing and, possibly, a full tear, leading to misalignment of the toe and pain under the ball of the foot.

Symptoms: What Does a Plantar Plate Injury Feel Like?

Patients often describe this injury as a deep, aching pain under the ball of the foot, particularly beneath the base of the second toe and associated metatarsal head.

Other common symptoms include:

• A feeling of walking on a pebble

• Swelling at the base of the toe/ball of the foot

• Pain when walking barefoot

• Discomfort when pushing off during walking, running, lunges or high impact sports

• The toe drifts up or towards the adjacent toe, mostly towards the first toe

• Increased pain on hills or in flexible shoes

How Is a Plantar Plate Injury Diagnosed?

Proper diagnosis starts with a review of symptoms, onset, activities, and shoes, followed by a hands-on exam to assess joint stability and motion, toe position, swelling and foot structure. A straightforward sign your podiatrist looks for is whether lifting the toe upward reproduces pain or reveals looseness-drawer tes-.

In confirming the diagnoses, Dr. Stern may also use:

• X-ray to check bone alignment

• Ultrasound to check the ligament in real time

• MRI in more complex or long-standing cases

Stages of Plantar Plate Injury

Plantar plate injuries range from mild to severe:

1. Grade 0: Pain with no tear, swelling, stable toe

2. Grade 1: Mild sprain or early microtears, swelling

3. Grade 2: Partial tear with toe drifting-hammertoe, unstable joint

4. Grade 3: Significant tear and increased toe drifting deviated or dislocated, overlap

5. Grade 4: Full-thickness tear or toe dislocation-hammertoe, deviated

Early treatment prevents the injury from progressing into these later stages.

Treatment: What Actually Helps

Most plantar plate injuries do not require surgery. The key is reducing strain/load on the ligament so it can heal.

1. Offloading the Joint

This is the cornerstone of treatment and may include:

• Rocker shoes

• Custom orthotics

• Metatarsal pads

• Carbon-fibre shoe inserts

• Taping or toe-alignment straps

These redistribute pressure/load away from the injured area.

2. Footwear Modifications

Supportive footwear with a stiffer sole or rocker shoe helps prevent bending forces through the forefoot.

Barefoot walking usually makes symptoms worse.

3. Activity Adjustments

Temporary rest and or reduction  of:

• Running

• High-impact sports

• Long walks/hikes

• Hill or stair workouts

• Lunges

• Or any high-activity sports

This protects the ligament while healing begins.

4. Anti-Inflammatory Strategies

Ice and anti-inflammatory medications may help with pain if they are appropriate for you.

5. Physical Therapy

Strengthening the muscles that support the toes helps restore stability and balance. Various modalities from a physiotherapist can help, e.g. ultrasound or laser

6. Regenerative Treatments

Platelet Rich Plasma, prolotherapy injections.

When Is Surgery Needed?

Surgery is considered only when:

• Pain and toe drift continue despite conservative treatment

• The toe drifts out of position-dislocation

• There is a complete tear

• Daily activities are limited

Surgical repair typically involves reattaching the ligament and correcting the forces that caused the injury. 

Who Is Most at Risk?

You may be more prone to plantar plate injury if you:

• Are between 40 and 75

• Have a bunion

• Wear flexible or high-heeled shoes

• Walk or run long distances

• Forefoot exercises

• Have a long second metatarsal/toes

• Have flat feet or very high arches

These patterns consistently show up in patients with this condition.

Prevention: Protecting the Plantar Plate

• Wear supportive rocker shoes

• Avoid excessive forefoot pressure

• Change worn-out footwear regularly

• Strengthen the intrinsic foot muscles

• Custom orthotics 

• Seek early treatment for any new forefoot pain

Because most plantar plate injuries develop gradually, prevention is highly effective.

When to See Dr. Stern

If pain under the second toe has persisted for more than a few weeks, especially if you notice swelling or the toe beginning to drift, it’s time for a proper assessment.

With over three decades of clinical experience in podiatric sports medicine and biomechanics, Dr. Stern provides a precise diagnosis and an individualized plan focused on relieving pain, restoring stability, and preventing long-term issues.