5th Metatarsal Pain

by Karen
(Greensboro, NC)

For many months now I've been suffering from pain/soreness on the sides of my feet. The pain in my right foot is at the head of the 5th metatarsal and the pain in my left foot is at the back of the 5th metatarsal. The podiatrist diagnosed inflammation and recommended ibuprofen and new shoes, but encouraged me to continue walking 3 miles per day. Her recommendations only made the pain worse. After a time I saw my primary care doctor who order an MRI. The MRI seemed to suggest a stress fracture at the head of the fifth metatarsal on the right foot. (At that time my left foot was not bothering me very much.)

I spent over 6 weeks in a boot with no improvement. My PCP referred me to an orthopedic surgeon who diagnosed tight Achilles tendons and recommended stretching exercises. When I asked him if I had not had a stress fracture. He replied that he didn't know, but that I had had a stress reaction After several months of stretches, I am not better. In fact I would say my pain is worse at times than before.

The pain is more intense upon waking, but usually lessens as the day goes on. There is a slight protrusion in both areas and pressing of these areas produces pain. The pain is worse when shoes make contact with the areas regardless or whether or not the shoe is loose or snug. I've tried orthotics in my shoes with no results. I've tried wearing just athletic shoes with no improvement. Regardless of the shoes I wear, eventually during the day, they will start to irritate these areas.

I no longer know where to turn for help. I've had 3 different diagnoses with 3 different courses of treatment with which I've complied. None have produced any improvement. I am 54 years old and don't want to face foot pain for the rest of my life if there's something I can do.

I would appreciate anything you could suggest.

RESPONSE

Hi Karen,

A stress reaction of bone is suggestive of a possible fracture. Not a complete fracture but perhaps could be described as just short of being a fracture. So you may be dealing with a bit more of a problem than just a strain.

I do not know if this is part of your problem or not, but I have found in certain cases wearing a cam walker, or walking boot in many instances will actually aggravate pain in the fifth metatarsal bone. Many of these walking boots are too narrow for certain foot structures.

So, in theory, if this is the case in your situation, then you may have wasted six weeks in the boot.

You may have a tight achilles tendon and in those cases that may put strain on the fifth metatarsal head which may have lead to your original pain but quite frankly, stretching in a 54 year old, hoping to stretch the achilles tendon is pretty much a waste of time as stretching is much more beneficial in younger people and only marginally beneficial the older we get. I would think the heel lift would be of more benefit.

Ok, so where do we go from here. If you were to walk into my office tomorrow the first thing I would consider would be a bone scan. A bone scan is much more sensitive to micro fractures then is an MRI.

If a bone scan is suggestive of a fracture then I would look into some kind of walking boot that does not actually aggravate the area so that you can walk and heal at the same time.

If the bone scan is negative and from the MRI we know there is no soft tissue damage then I would suggest sending you for physical therapy to move things along at a quicker rate.

As a side note, one condition that can also cause pain at the level of the fifth metatarsal head is a bursitis which can either occur on the bottom of the metatarsal head or the side of the head. This is a condition that a good podiatrist would be aware of but other types of doctors could easily miss this. If the painful area happens to be slightly swollen and perhaps a little bit red, then an inflamed bursal sac has to be considered as well.

We have not really discussed the left foot pain but it would seem to me the worsening of that pain has more to do with the added burden placed on your left foot from wearing the boot on the right foot. I am essentially suggesting that once you clear up the problem with your right foot and start walking more normal, your left foot should also feel better.

As a final thought, I would also look at the sneakers you wear to go for your walks. In most cases when people develop foot pain with no history of trauma, the shoes they wear can be part of the problem.

Marc Mitnick DPM
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