Therapeutic goals
Reduce forefoot pain and limit mechanical stress on the injured plantar plate.
Preserve and gradually restore metatarsophalangeal mobility, according to clinical tolerance.
Progressively strengthen the intrinsic foot muscles and the forefoot stabilising muscles.
Improve control of the foot arch and the distribution of plantar pressure.
Correct the biomechanical factors that overload the affected metatarsophalangeal joint.
Prevent recurrence and gradually return to functional and sporting activities.
Techniques used
Adjust activities according to pain and temporarily limit activities that increase stress on the forefoot. Pain-relieving techniques suited to the symptoms. Gentle manual therapy of the joints and periarticular tissues, avoiding any excessive direct stress on the injured plantar plate. Footwear advice and, if needed, discussion of a forefoot offloading device or a suitable foot orthosis.
Gentle mobilisation of the tarsal, midfoot and ankle joints. Progressive mobilisation of the affected metatarsophalangeal joint, only within pain-free ranges and according to joint stability. Maintenance of toe mobility without excessive tension on the plantar plate. Triceps surae stretches if ankle dorsiflexion is limited, to reduce excessive stress on the forefoot. Avoid: forced mobilisation of the affected toe into dorsal extension, repeated tensioning of the plantar plate and painful manipulation of the metatarsophalangeal joint.
Progressive strengthening, first targeted then functional, according to pain and the stability of the affected joint: intrinsic foot muscles, in particular the interossei, lumbricals and abductor hallucis depending on the affected ray; the forefoot stabilising muscles; tibialis posterior and the fibularis muscles, depending on the deficits identified; triceps surae, with a cautious progression of weight-bearing exercises to limit forefoot overload.
Single-leg balance exercises on a stable surface, then progression according to tolerance. Work on foot-strike control and foot and ankle stability. Retraining load distribution between the rearfoot and forefoot, without overloading the affected ray.
Gradual return to prolonged walking according to symptoms. Gradual reintroduction of weight-bearing activities, monitoring pain during exercise and over the following 24 hours. Progressive return to running only after clinical improvement and good tolerance of walking and functional exercises. Patient education on adjusting training loads, footwear, managing forefoot overload factors and preventing recurrence.
Exercise programme
Suggested exercises, to be adapted to the stage of recovery:
- Short foot exercise at low intensity, pain-free
- Active toe mobilisation within tolerated ranges
- Foot arch control work without excessive toe gripping
- Isometric then dynamic strengthening of the intrinsic foot muscles
- Progressive work on the ankle stabilisers
- Calf raises only after clinical improvement, with load progressed according to tolerance
Avoid at first: picking up objects with the toes, repeated painful calf raises and exercises that strongly load toe flexion or extension if they reproduce the pain.
Protocol details
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