Frequently Asked Questions and Answers about Plantar Plate Injury

Frequently Asked Questions and Answers about Plantar Plate Injury A plantar plate tear causes persistent pain and swelling in the ball of the foot. The article discusses the frequently asked questions and answers about plantar plate tears.

Regarded as a common, painful and distressing condition, Plantar Plate sprain (also known as Plantar Plate Tear) can affect people of all age groups and is one of the easily missed and probably one of the most underdiagnosed conditions. This is for the simple reason that many people do not know what a plantar plate is all about. So what is a plantar plate? The plantar plate is a thick, fibro-cartilaginous ligament type structure on the bottom of the foot between the base of the toes and the metatarsal behind the joint. The plantar plate is designed to keep the toe in line and prevents it from over extending or drifting. Unlike most other ligaments, there is no muscle associated with the plantar plate. In some instances, the ligament tears or becomes overstretched, which causes pain and can lead to toe dislocation. The pain is often misdiagnosed as a neuroma. Generally, plantar plate sprain occurs in middle aged women whose feet have an increased tendency to over-pronate or roll in. The condition most commonly occurs in the second toe and is generally associated with a bunion and a hammer toe. For podiatrists treating such conditions, medical billing outsourcing is a good option to meet their medical claim submission tasks.

Here are some of the frequently asked questions and answers about plantar plate sprain – Q: What is a plantar plate sprain?

A: As mentioned above, the plantar plate is a fibrous thickening of the joint capsule under the ball of the foot. Injuries of the plantar plates include partial tears through to complete rupture.

Sprains to the ligament can occur in varying degrees of severity and these include – 

Grade 1 – This type of sprain occurs when a ligament becomes overstretched resulting in micro tears and ligament laxity.

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Grade 2 – This type of sprain includes partial tearing of the ligament causing severe pain and in some cases, partial joint deformity.

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Grade 3 – Grade 3 sprain is a complete tear of the ligament that leads to intense pain with visible joint deformity.

Q: What causes these sprains?

A: Plantar plate injuries are either the result of overuse or from specific damage to the toe and its associated joints. When excessive pressure is placed through the metatarsal bone area (particularly on the metatarsal head that faces the greatest force loads) while walking, running or jumping, it may result in the plantar plate ligament giving out over time and developing a tear. In most cases, these injuries develop slowly over time from a progressive degeneration of the ligament from repetitive overuse or abnormalities, including - biomechanical abnormalities (a short or elevated first metatarsal, or a long second metatarsal), use of incorrect shoes, bunions (hallux valgus) and steroid injections (that cause weakening and thinning of the plantar plate ligament).

Q: What are the common symptoms?

A: Plantar plate injuries are typically more common in women aged between 30-40 years. In most cases, these injuries tend to involve only one toe at a time, which is often the second toe.

Persistent pain and swelling under the ball of the foot and extending towards the toes are one of the most common symptoms associated with the condition. Other related symptoms include 

A feeling that there is not enough cushion between the foot bone and the ground

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Pain that worsens when the toe is flexed upwards

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Possible swelling and/or redness on the foot near the toe

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Shifting of the toe

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Feeling as if you are 'walking on the bones of your foot'

If left untreated, the condition can become chronic, causing greater deformity or even the development of hammertoe. As the deformity progresses, the cartilage in the joint can become eroded, leading to arthritis and increased pain. Further damage to the plantar plate may cause the toe to dislocate, resulting in a more difficult surgical correction.

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Q: How are plantar plate sprains diagnosed and treated?

A: Diagnosis of a plantar plate injury is often a challenging procedure, due to the complex nature of the anatomy of the foot. A detailed medical history evaluation and physical examination of the painful area is essential to determine the cause, extent and severity of the injury. Podiatrists or other specialists will move and manipulate the troubled toe joint into various positions to evaluate the nature and extent of deformity and the location of pain. They will ask numerous questions about pain symptoms and how it affects the patient. Further, diagnostic imaging tests like X-rays, Ultrasound, Arthrogram and MRI (magnetic resonance imaging) will be performed to determine the degree and angles of the toe deformity. The main goal is to rule out other conditions and to determine the severity of your problem.

Initial treatment of the tear will focus on symptom relief. This involves identifying and eliminating the deforming activity or force that is actually casing the injury. Treatment initially consists of anti-inflammatory medications, plantar flexion strapping of the toe, toe splints and pads, footwear modification, physiotherapy (stretching the calf muscles) and activity modification to reduce loads under the affected metatarsophalangeal joint.

In acute cases, physicians may prescribe a boot to take weight off the ball of the foot. Tape may be wrapped around the toe to hold it in a downward position for several weeks. If there is any specific deformity from side to side, the tape can hold the toe in the opposite direction, which allows the ligament to heal without continued strain. In some cases, custom molded orthotics may also be prescribed.

In chronic cases, if the toe has drifted apart significantly – which indicates that the ligaments around the toe have been stretched - surgical treatments to repair the plantar plate ligaments is essential to get the toe back into correct position. Normally, the recovery period after direct repair of the plantar plate is usually 4 -8 weeks. During the recovery period, patients need to be off the foot while healing and crutches are often recommended. Patients may have to use a removable boot or a cast, depending on the extent of the surgical repair.

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Q: What are the medical codes for reporting plantar plate repair?

A: If the procedure performed was designed to repair the position and instability of the toe with repair of the metatarsal-phalangeal joint capsule/ligament, then the following CPT codes are appropriate – 

28313 - Reconstruction, angular deformity of toe, soft tissue procedures only (e.g. overlapping second toe, fifth toe, curly toes)

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28899 - Foot/toes surgery procedure

Related ICD-10 Codes ICD-10 coding is not easy, as the specific code you choose will depend on your diagnosis (based on your findings both pre- and intra-op) and the etiology. Sprain of the metatarsophalangeal joint code category will include a 7th character (A, D, S). Some of the related codes include S93.52 - Sprain of metatarsophalangeal joint of toe S93.521 - Sprain of metatarsophalangeal joint of right great toe 

S93.521A …… initial encounter

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S93.521D …… subsequent encounter

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S93.521S …… sequela

S93.522 - Sprain of metatarsophalangeal joint of left great toe 

S93.522A …… initial encounter

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S93.522D …… subsequent encounter

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S93.522S …… sequela

S93.523 - Sprain of metatarsophalangeal joint of unspecified great toe 

S93.523A …… initial encounter

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S93.523D …… subsequent encounter

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S93.523S …… sequela

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S93.524 - Sprain of metatarsophalangeal joint of right lesser toe(s) 

S93.524A …… initial encounter

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S93.524D …… subsequent encounter

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S93.524S …… sequela

S93.525 - Sprain of metatarsophalangeal joint of left lesser toe(s) 

S93.525A …… initial encounter

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S93.525D …… subsequent encounter

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S93.525S …… sequela

S93.526 - Sprain of metatarsophalangeal joint of unspecified lesser toe(s) 

S93.526A …… initial encounter

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S93.526D …… subsequent encounter

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S93.526S …… sequela

S93.529 - Sprain of metatarsophalangeal joint of unspecified toe(s) 

S93.529A …… initial encounter

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S93.529D …… subsequent encounter

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S93.529S …… sequela

Q: How to prevent plantar plate sprains?

A: Examining and diagnosing abnormal foot mechanics early on can help prevent plantar plate injuries. Patients who happen to notice the symptoms early and have them evaluated by a podiatry specialist can receive the best treatment and avoid further complications. Prevention of plantar plate strains focuses on optimizing foot function and minimizing abnormal stress or injury to the foot.

Podiatry coding and billing can prove complex. Busy physicians can take advantage of podiatry billing services provided by established medical billing companies to meet their claim submission and follow-up requirements.

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