Plantar Plate Pearls for Podiatric Practice

Welcome back to Podiatry Today Podcasts. I'm Dr. Jennifer Spector, the Assistant Editorial Director for Podiatry Today. In this episode, we will talk with Erin Klein, DPM about plantar plate pathology. She's a prolific researcher on this topic and was highlighted, in part, due to these accomplishments, in our June 2022 Changemakers feature.

Fellowship trained at the Weil Foot and Ankle Institute, Dr. Klein has published and presented numerous studies, both in and out of the podiatric space. She recently had the ability to analyze and present a 10 year follow up study on plantar plate repair. Dr. Klein's received more than 10 awards for scientific manuscript podium presentations, at various national meetings in just the past decade alone. Specifically, this is in addition to more than 40 research awards at national conferences over the past 10 years that she collaborated on.

We're very grateful to have Dr. Klein with us today, to share a little bit about the depth of her experience with this pathology, both in the lab and in clinical practice. Thank you so much for being with us today. Tell us a little bit about your experience with researching plantar plate pathology.

Erin Klein, DPM: This is a very interesting story that I hope people enjoy. When I was a third year resident, one of our attendings, she was very creative in how she chose to teach us, which was kind of fun. She brought in Play-Doh one day, and she handed us, there were six of us residents, so she handed us six foot models. And she said, "All right, everyone's going to reconstruct a metatarsophalangeal joint using Play-Doh. And we all kind of laughed at her, because this is something you would like, let's make something with Play-Doh. It's kind of like a kindergarten teaching method. Surprisingly, it was very interesting to see what we chose to reconstruct, because not one of us got it right. And I remember building that MTP, and I remember taking the Play-Doh and making a plantar plate, and being like, "You know what? I don't think I've ever really seen this in the OR."

So of course, I started looking for it. And it was right about that time that I interviewed for the fellowship at the Weil Foot and Ankle Institute. And on my interview day, the way interviews were done at that time, I spent my day in the OR with Dr. Weil Jr., and he had three different plantar plate repairs. So I finally got to see this plantar plate that I couldn't reconstruct with the Play-Doh, actually live and in person. And it was interesting, because I was training at a VA, so you can argue that, the feet at the VA are a little bit different than the feet you're going to see in private practice. But I had never seen the MTP joint, or understood it the way that I did after I left the OR, during my fellowship interview.

Erin Klein, DPM:

And I remember thinking that day, "God, I hope I get this fellowship, because I would really like, that was awesome." That was so cool, thinking about how many patients I had seen, probably with plantar plate pathology, that I didn't even recognize, because I didn't understand it. So I was really excited to come to the Weil Foot and Ankle Institute for fellowships, specifically to study the plantar plate and to study elective forefoot surgery, because it's something that we do here that's just done differently. And the level of understanding of the complex interactions of the forefoot is something that I don't think is a profession we understand very well. So to come here, and then get to spend an entire year looking at so much, so many things related to the plantar plate, was amazing.

So that's how it all got started, and since then, between the OR, different cadaver labs that we've had the ability to conduct, spending time in the Rosalind Franklin Gross Anatomy Lab, to understand some of that pathology a little better, I think that's where I really started to understand what the plantar plate was, and how things started to interact. Because frankly, the dissection you can get on a cadaver is exceptionally different than what you can do on a live human being in the OR. They're not even comparable. So to have the ability as an fellow and attending to go back to a basic science lab and start to take things apart, to put them back together, to then take that knowledge and apply it to actual live humans that you're trying to treat was amazing. And from that, that's kind of where things started.

And then, we started to look at, well, if we understand this, how is it best to teach this to the rest of the world? That's what led us, led me and Dr. Weil Jr, to start to look at some of the studies that we've published, and we created a cohort of humans who had plantar plate repairs while I was a fellow. And from that cohort of humans, we were then able to extrapolate data, because we had inter-operative observation on all of them. So we were able to say, "Okay, this is what we saw in the OR, now let's go back and trace this backwards, to what we should have seen on their clinical exam, on their X-rays, on the ultrasound, on the MRI." And then, kind of start to compare some of those imaging modalities for purposes of what's best.

I think that's where things were. That was 10 years ago, and since that time, I think that we were able to take the knowledge we acquired that year, and start to apply it to patients over the next 10 years, which has really allowed us to do a lot of plantar plate work, both operative and non-operative. Definitely more operative than non-operative, because non-operative treatment doesn't work that great. But we've been able to actually then see what we do in clinic every day.

Many of our researchers in pediatric medicine are brilliant, but don't spend a lot of time in clinic. I think that spending the amount of time in clinic and the OR that I do, has actually allowed me to have a little bit of a different perspective on research that is based in science, but has a practical application to everyday life. And that's really what I strive to do with research, is to take the problems I see in clinic and say, "All right, this is a problem." And then, come up with ways to fix it. Once we find a way to fix it, then go back and research how we can make it better. So that's where a lot of the plantar plate stuff has come from.

What's been interesting is our ability to travel to different conferences, both podiatric and orthopedic, to have discussions with Mike Coughlin, and a couple of the other orthopedics throughout the world, that do forefoot and plantar plate stuff. And then from those conversations, we tend to have visitors in clinic from different countries, that can then input what they're doing in their countries, to compare it to what we're doing here. And we can have those high level discussions that allow us to really drive patient care forward.

It's been an absolutely amazing journey. It's so cool to talk to people from really, around the world, about what they're doing, and some of the things they're seeing, and some of the, I guess, obstacles they face. I know in Brazil, where that's Caio Nery, who's down there in his group of orthopedics who are working on plantar plate stuff down there. It's interesting, because they don't have nearly the amount of technology, equipment, or inter-operative instrumentation, to do some of the same things we do, yet they're able to still fix plantar plates after we have these discussions. So that's been interesting to see, how they're facing challenges and conquer them.

Jennifer Spector, DPM: I think your point about having a practical application to evidence based research is so key, because I think some people may feel a disconnect there. And to be able to make that connection and make that, bridge that gap, is huge.

Erin Klein, DPM: It is so important. I get so frustrated when I'm reading journals or articles, and there's this point about how important this one thing is. And then you look at that one thing, and you're like, that's very interesting. I see why it's important. But yeah, out here in Libertyville, Illinois, I'm not really sure how I would, what question I would ask, or what test I would obtain, that would actually give me that information. So finding a way that someone in, we're going to say rural America, versus someone in a teaching institution, trying to span that gap with research so that everybody can apply it is, it's a challenge. I don't look at it that way. I look at it as an exciting adventure, but it is a challenge, and that's what I try to do.

I think that is one way that I can use my brain. I've been told it's a very special brain. Many of my partners here, frequently tell me that the way my brain works is not the way everyone else's brain works. And I'm okay with that. I fought that for a long time. But I'm okay with that now, because the way my brain works can potentially help patients that I don't even know about millions of miles away. And that's awesome for me. That's why I do what I do.

Jennifer Spector, DPM: When we're working through trying to figure out how to maximize outcomes. We've all found that the workup and the preoperative phase sometimes is one of the most important parts.

Erin Klein, DPM: For sure.

Jennifer Spector, DPM: Knowing that, what do you feel is the most important aspect of the workup for plantar plate pathology?

Erin Klein, DPM: I've thought about this question since I read it for a very long time. And I think it's suspecting the problem is there. If you suspect that there's a problem in a foot, let's say a plantar plate tear, you start to ask the questions that in your brain related to plantar plate tears. Once you start asking those questions, whether it be x-ray, ultrasound, MRI, whatever imaging modality you want, if you ask the question, you're more likely to find it. If you ignore the fact, or say the plantar plate doesn't matter, or say the plantar plate isn't a thing, if you don't give the plantar plate the time of day and you don't suspect it's there, you'll never find the pathology. So I think that's probably the most important thing, is suspecting a problem is there. Because if you ask the questions, you're going to find a better answer than if you just ignored it.and don't ask the questions.

Jennifer Spector, DPM: So once you suspect that it's there and you identify that it's there, that now you've proven it. This is the million dollar question that there's probably not a good answer to. But in your opinion and in your experience, how do you go about deciding what the best procedure then is for this patient?

Erin Klein, DPM: So for this one, and for me, it's the procedure that we've done thousands of times here. It's the dorsal approach, direct repair of the plantar plate from the dorsal via a Weil osteotomy. For me, that one is the one that's best, it's the one. It didn't come out first. I think you can argue there were other techniques first. But it's that particular technique. You perform your Weil, you push the Weil back, and fix it with the temporary pin. And then you can see so much of the plantar plate, and so much of the pathology that occurs on the dorsal aspect of the plantar plate that, that way you can fix it, move your osteotomy back out to the proper length, put a screw in it, and then get the patient back to life. There are many sets out there that are many techniques that have come, particularly since the dorsal approach via the Weil metatarsal osteotomy was published.

I find that many of them are, the incisions are a little bit bigger, the dissection is a little bit more. So that for me is not the best. The one that works best for me is the, it's the Complete Plantar Plate Repair System, Arthrex. And I don't know if that is because that's how I was trained, that's the one I'm the most comfortable with. That's the particular procedure. I've seen everything I think that could possibly go wrong in the OR with that procedure go wrong. And I've seen us be able to get those patients better. So I have a lot of confidence in that particular technique. Now is everyone going to have that confidence? No. Is that the technique for everyone? Definitely not. But for me, as a human, and as a physician and a surgeon, that's the one that I'm the most comfortable with.

Jennifer Spector, DPM: What's your typical post-op course for that technique?

Erin Klein, DPM: So with this technique, they come out of the OR, they're blocked. They are in a bandage, and they're in a surgical shoe. Now, some of this does depend on what other procedures were performed, but just assuming we're do... So that part I think is obvious. And if you're doing a lapidus with this, are you doing some first MTP joint fusion, things may change. But for someone who just isolated second MTP plantar plate repair with a Weil osteotomy, they're going to be an advantage in the surgical shoe. They're sent home that day. They're told, "Go home. Keep your foot up. You're allowed to walk on your feet. But where you're allowed to go is very restricted." So we're a little bit strict, I think that first week, with how they're allowed to weight bear. They're allowed to weight bear enough to get from the couch to the bathroom, the bathroom to the kitchen, the kitchen back to the couch, with the understanding that they're walking primarily on their heel, and that they are not doing too much at any one point in time.

One of the key things I find to tell patients in that first week is, if your foot starts throbbing, if the bandage starts feeling tight, or if your pain's getting better and then all of a sudden gets worse, you did something that your foot doesn't like. So you have to let your body talk to you and tell you what to do. If you convince people, that first week, to really be very sedentary, maybe convince them that Netflix marathons, they haven't seen Tiger King yet. Go watch it. What have you. Bridgerton, that's another one that I've been hearing from patients that they like to watch that first week. But go sit, stream the marathon. Like really, don't do anything. Patients typically do so well that, when they come into the office, they have, for that first postop visit, which is somewhere between day seven and 10, they have very little pain. That's good. I don't like phone calls about people in pain. And then, people don't like being in pain, so that's a good thing.

So their first postop visit is day seven to 10. On that day, the dressing comes off. We take a look at the incision, obviously, we expect that it's going to look amazing. If it looks less than amazing, we address whatever problem it is. Typically, if everything is perfect, they will go into a stiff soled, wide running shoe. That could be a Brooks, that could be a Hoka, that could be, maybe they don't have access to those. That could be a less amazing running shoe with a Morton's extension, or a full length steel insert in that shoe, because you want the shoe to be stiff. So they're put into that shoe with a compression sock, either to the ankle or the knee, whatever feels better to them. And then, they start physical therapy on that day as well. And that's key. But we're going to pause on that for a second, and go back to the footwear, and the weight bearing restrictions.

So at this point, we tell patients that they can be on their foot somewhere, it equates to about five to 10 minutes at a time, for about, in a total amount of an hour and a day. So the guideline we give them is, however many weeks you are from surgery, that is the total amount of time in the day that you can be on your foot. So if you are one week out from surgery, you have a total of one hour in that day you can be on your foot for the entire week, until you get to two weeks, and then it goes up to two hours. What we find patients doing is, they're on their foot to about five to 10 minutes at a time at that point, and they're like, "I got to sit down." And then the next week, it's about 10 minutes, maybe 12. And then the week after that, they're about up to 15. And the math doesn't always quite work, but there's a slow progression of weight bearing during that time.

The compression stocking, or sock, and their shoe, it goes on their foot in the morning, and it stays on their foot the entire day. And patients are like, "Well, but what if the shoe gets tight? Or what if it starts to hurt?" I'm like, "Well, typically when that happens, you've been on your foot too much. And don't take the shoe and sock off, because that's our natural instinct. Sit down and put your foot up until it goes away." And interestingly I've found, that concept actually slows people down more than weight bearing instructions, for what that's worth. So that's that. T.

They're allowed to shower, because we use internal subcuticular closure with Steri-Strips. So they're allowed to shower and get their foot wet. They are not allowed to soak their foot, do anything like that. And then the other part of the post-op that goes with their physical therapy is their bracing, their toe in as much plantar flexion as they can obtain, slightly uncomfortably. And they wear that brace every night, probably for the next six to eight weeks, maybe longer. The point of the bracing is to keep the extensor tendons nice and lengthened, because the extensor tendons, if you don't lengthen them, they are going to naturally contract, which then leads to toes floating. It leads to the toe's inability to get to the floor, and it actually can stretch the plantar tissues that we're trying to protect.

Now, physical therapy. They start physical therapy on that first postoperative visit. Physical therapy is aimed at mobilization and decreasing scar tissue, initially. So there's a lot of education on the bracing, a lot of pulling the toe into plantar flexion. Once the incision is healed, which is sometime in the next week, patients start with intrinsic muscle work on the foot. So this includes toe crunches and toe curls, picking marbles up with their toes, picking pencils up with their toes. In doing that, they're also working on stretching their Achilles, and addressing any other functional deficit the therapist finds in the foot.

Now they're also, if they've had another procedure, working on whatever they need for that procedure too. But what we find is that, so many of these patients really, actually many people, lack intrinsic strength in the intrinsic muscles of the foot. So these are your lumbricals, your interossei muscles. We don't think much of those little guys, but really, they do a lot of things and they're very important, so the therapies mostly aimed at that. Once the osteotomy is healed, then we progress to normalized weight bearing and things of that nature. So that's the first postoperative visit. There's a lot of things that go on at that visit.

Our next visit is somewhere between three and four weeks later, which is more of an incision check than anything else. As the patient progresses after that first month, I find that it's important to tailor your postoperative protocol to what the patient is able to do. Because there is a frustration that occurs between weeks four and six as to, "Why am I not better yet?" And then you remind the patient, we talked about this preop, it's a long postop recovery, and you have to kind of address the mental component of their healing. Right about week six to eight, patients are released to do weight bearing exercise to their tolerance.

Erin Klein, DPM:

Now, me saying they can do this and them wanting to do it two completely different things. But at the point that the second metatarsal is healed, they can start to be up and around, weight bear a little more, start to walk a little more. Somewhere between three and six months, and that is a big timeframe, but it's also very variable, patients start to have days where they forget they had foot surgery. Somewhere between months six and nine, patients are having more good days than bad. And somewhere around 12 months, we consider that quote, maximum medical improvement, for lack of a term. With that, there's also the concept that's in an optimal course. Now, if patients aren't doing so well, many times a physical therapy can be extended for quite some time. Probably the most common complication is dorsal scar tissue at the MTP that's painful and limiting.

I find patients don't really care if their toes touch the floor, and if their toes float a little bit. But if they hurt, then that matters. So if they're continuing to have pain, continuing to have problems, right around month 12, we consider releasing that dorsal scar tissue with a percutaneous procedure. It's done in the OR, but it's just a percutaneous procedure to cut through some of that scar tissue, and then manipulate that toe down into plantar flexion. Then they continue with physical therapy, really aimed at lengthening all that scar tissue. That takes about three months to recover from that.

Jennifer Spector, DPM: So to sort of conclude things today, is there anything else that you have learned along the way that you'd really like to share with our audience, on the topic of plantar plate pathology?

Erin Klein, DPM: Think about plantar plate pathology. When you have forefoot pain, you have to think about plantar plate pathology. I find that if you think that it's there, if you're suspicious that it's there, you order the right testing, you're going to find that it's there. And this isn't something where you can be an ostrich, and stick your head in the sand. You actually need to address it. I think that there is a learning curve for this, and it's an interesting learning curve, because it's not just learning how to work the instrumentation, not just learning the procedure. I mean, you can watch, there's YouTube videos out there. You can watch many of us do this, and know how to do this.

What I find though, is you have to be patient with yourself. Right? Because surgeons are high-achieving individuals. We want it. We want it our way. We want it now. We don't want to struggle. But the fact of the matter is, to learn a new surgery is actually rather challenging. So you have to be patient with yourself.

While you're in the OR, one must remain calm. Because let's face it, stuff goes wrong all the time. Like equipment doesn't work, something doesn't show up. Panicking does not help. And being grumpy does not help. Because if you're grumpy, everyone else in the room's going to be grumpy, and then everyone's going to make mistakes, and that's when stuff goes really bad. So remaining calm, even if you're fuming on the inside, remaining calm in your face, and your demeanor, and your nonverbal communication, is probably really key.

And then the other thing is, trust the repair and get these folks into physical therapy. So frequently, when we get second opinions, or when we have to redo plantar plate repairs that others have done, I find that the key thing that was missing was adequate physical therapy. And if I didn't say it, trust yourself. Trust yourself, trust your gut, trust your training, trust your hands, trust your brain. Trust yourself. Because this is something that, it's a procedure that you can learn to do. You can learn to do it very well. But trust yourself.

Jennifer Spector, DPM: That's wise advice for sure. And we're very grateful to you, Dr. Klein, for joining us today for this episode of Podiatry Today Podcasts. And thanks, as always, to the listeners for joining us as well. Make sure to check out other episodes on podiatrytoday.com., Spreaker, Spotify, Apple Podcasts, and your favorite podcast platforms.