Plantar Plate Tear and Second MTP Joint Instability: Diagnosis and Surgical Repair

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Plantar plate disruption at the second metatarsophalangeal (MTP) joint — tearing of the fibrocartilaginous plantar plate at its distal phalanx attachment from chronic overloading or acute hyperextension — is the most common cause of second MTP joint instability and crossover toe deformity, producing plantar forefoot pain, swollen ‘sausage toe,’ and progressive dorsal and medial displacement of the second toe. The plantar plate tear is frequently misdiagnosed as a ‘capsulitis’ or metatarsalgia — and delayed diagnosis allows progressive joint subluxation that ultimately requires more extensive surgical correction.

Anatomy, Grading, and Diagnosis

Plantar plate anatomy: a thick fibrocartilaginous structure on the plantar surface of the MTP joint — attached proximally to the metatarsal neck via the joint capsule and distally to the base of the proximal phalanx; provides the primary restraint against MTP joint dorsiflexion and lateral drift of the proximal phalanx. Plantar plate tear grading (Nery): Grade 0 — plantar plate attenuation without tear; Grade 1 — distal attachment tear <50% width; Grade 2 — distal tear >50% width; Grade 3 — complete transverse tear with proximal retraction; Grade 4 — extensive tear with button-hole deformity. Clinical diagnosis: plantar MTP joint tenderness (most tender 1–2cm proximal to the web space, directly on the metatarsal head, not at the web space as in Morton’s neuroma); positive drawer test (Lachman test of the MTP joint — 2–3mm dorsal subluxation of the proximal phalanx on the metatarsal head is abnormal); ‘V sign’ — medial and lateral deviation testing for collateral ligament integrity. MRI: high-resolution MRI of the forefoot confirms plantar plate tear grade and location; axial images show the plantar plate discontinuity at the distal phalanx attachment; coronal images show the degree of joint subluxation.

Surgical Repair

Weil osteotomy with plantar plate repair: the standard surgical approach — shortening Weil osteotomy of the second metatarsal neck reduces plantar plate tension and decompresses the joint, allowing plantar plate repair; dorsal approach to the MTP joint; Weil osteotomy performed first; plantar plate reflected and mobilized through the joint; direct suture repair of the distal attachment with suture anchors to the phalangeal base; flexor tendon transfer augmentation for Grade 3–4 tears. Recovery: protected weight-bearing in a wooden-soled shoe 4–6 weeks; K-wire stabilization of the MTP joint for 4 weeks; return to normal shoe wear at 8–10 weeks. Outcomes: 85–90% improvement in pain and deformity correction; 10–15% redevelop mild recurrent deformity. Dr. Biernacki at Balance Foot & Ankle diagnoses and surgically repairs plantar plate tears and second MTP instability at our Bloomfield Hills and Howell offices. Call (810) 206-1402.

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Frequently Asked Questions

When should I see a podiatrist?

See a podiatrist for any foot or ankle pain that persists more than 2 weeks, doesn’t improve with rest, limits your daily activities, or is accompanied by swelling, numbness, or skin changes. People with diabetes or circulation problems should see a podiatrist regularly even without symptoms.

What does a podiatrist treat?

Podiatrists diagnose and treat all conditions of the foot, ankle, and lower leg including plantar fasciitis, bunions, hammertoes, toenail problems, heel pain, nerve pain, diabetic foot care, sports injuries, fractures, and foot deformities — both surgically and non-surgically.

What can I expect at my first podiatry visit?

Your first visit includes a full medical history, physical examination of your feet and gait, and in-office diagnostic imaging if needed (X-rays, ultrasound). We’ll discuss your diagnosis and create a personalized treatment plan. Most visits take 30–45 minutes.

Need Treatment at Balance Foot & Ankle?

Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients at our Howell and Bloomfield Township offices.

Book Online or call (810) 206-1402

Most Common Mistake We See

The most common mistake we see is: Waiting too long before seeking care. Fix: any foot pain lasting more than 4 weeks, or any sudden severe symptom, deserves a professional evaluation rather than more rest.

Warning Signs That Need Same-Day Care

Differential Diagnosis: What Else Could It Be?

Not every case of plantar plate tear is straightforward. In our clinic we routinely rule out three look-alike conditions before confirming the diagnosis. If your symptoms don’t match the classic presentation, one of these may explain the pain — which is why physical exam matters more than self-diagnosis.

Condition	How It Differs
Metatarsalgia	Pain at metatarsal head without instability; negative drawer test at MTP.
Morton’s neuroma	Burning into 3rd-4th toes with positive Mulder’s click; not between 2nd-3rd.
Stress fracture (metatarsal)	Point tenderness on shaft, not joint; callus on follow-up imaging.

Red Flags — When to See a Podiatrist Now

In Our Clinic: What We See