Pain at the base of the toes (the MTP joints) is common—and it’s often blamed on arthritis, bunions, or “wear and tear.” But one important cause is frequently overlooked: a plantar plate tear.
The plantar plate is a strong structure under the joint that helps stabilise the toe and supports the joint during walking and push-off. When it becomes degenerate or partially torn, it can trigger persistent pain, especially when you’re on your feet a lot.
Why this gets missed
Even when patients have clear symptoms, imaging reports don’t always identify plantar plate problems—particularly if the scan is performed as a static (non-moving) assessment. A standard ultrasound or MRI can be helpful, but the key issue is that some tears only become obvious when the joint is stressed in a controlled way.
This is where dynamic musculoskeletal ultrasound is valuable: the clinician can reproduce the movement that stresses the plantar plate and watch what happens in real time.
The clinical clue: pain exactly at the base of the big toe
Plantar plate tears can present as:
- Pain under or around the base of the toes (MTPs joint)
- Pain when walking, running, or pushing off the ground
- A feeling of instability in the toe in some cases
- Tenderness on the underside of the joint
People who spend long hours on their feet often notice symptoms more.
How ultrasound helps (and what makes it “better” than a routine scan)
Ultrasound can demonstrate degenerative plantar plate tears clearly when the assessment is done properly. One of the most useful techniques is dynamic testing: gently dorsiflexing (lifting) the toe during the scan. That movement can tension the plantar plate and reveal tearing or abnormal movement that may not be obvious at rest.
In other words: movement matters. A “still photo” approach can miss what a dynamic exam picks up.
What happens next if a plantar plate tear is confirmed?
Treatment depends on severity, how long symptoms have been present, and how much the joint is affected. Management often starts conservatively and may include:
- Footwear modification (stiffer sole, avoiding overly flexible shoes)
- Activity modification to reduce push-off load
- Offloading or taping strategies (often guided by podiatry)
- Targeted rehabilitation (strength, control, gait mechanics)
- Addressing contributing factors such as overload, biomechanics, and calf tightness
If symptoms persist or instability is significant, further interventions may be considered, and referral to a foot and ankle specialist may be appropriate.
Bottom line
If you have persistent pain at the base of the toe joints, a plantar plate tear is a diagnosis worth considering—especially when routine imaging has been “normal” or unhelpful. A careful clinical assessment combined with dynamic ultrasound (including dorsiflexion under the probe) can identify tears that are otherwise easy to miss.