Pain on the left side of my foot on the 5th Metatarsal

by Tom
(Canada )

In May 2014 the pain started after dancing.

The pain has been in the same place by the 5th Metatarsal and underneath the foot by the 5th Metatarsal. I had two x-rays one ultrasound scan and a CT scan and it shows no fractures or tissue damage as far as the image can produce. I have been icing the area 2/3 times a day. Also I have been to physio for TENS and ultrasound. The pain is worse when I wear shoes (any pressure on the side of the foot produces pain in shes)and I can only walk very short distances. I also visited a foot specialist (podiatry) who did a tracking on my foot by video camera and confirmed my walking was OK. I am waiting to see a Orthotic specialist. Any advice or suggestions would be greatly appreciated.

There is a very small bump on the side of my foot now by the 5th metatarsal. There is know big bruising. sometimes small bruising appears after wearing shoes.

Thanks

RESPONSE

Hi Tom,

I am going to make my observations based on the fact that you have had an ultrasound and CT scan both of which came back as normal.

One of the biggest culprits of pain on the outside of the foot near the fifth metatarsal bone is from the peroneus longus tendon. This tendon starts on the outside of the leg, comes down under the outside of the ankle bone and at the level of cuboid bone which is just behind the fifth metatarsal, cuts under the foot and travels all the way to the first metatarsal bone.

One of the biggest causes of pain is from the tendon in the area where it cuts underneath the foot. One of the biggest culprits of causing this pain are shoes that are too narrow in this area of the foot.

Typically, shoe width is measured at the ball of the foot, but many shoes, particularly dress shoes (I would imagine that dance shoes tend to fall under the category of dress shoes), are too narrow further back in the foot and thus the pressure of the shoe pressing against this tendon as it tries to move back and forth through the cuboid groove has caused an irritation resulting in pain. This pain would generally be felt on the outside of the foot extending to the bottom of the foot in that area.

Once you have the problem, almost any shoe will then cause irritation to the spot and for that reason the area never improves.

I have also seen this problem in people who wear certain sandals where the strap goes over the fifth metatarsal base-cuboid bone, and these too will aggravate the peroneus longus tendon.

Until you start wearing wide enough shoes in that area that stop irritating the tendon, the pain will probably not go away. You can have all the physical therapy in the world, but again, unless you eliminate the precipitating factor (narrow shoe), the therapy is essentially a waste of time.

I have also found that a cortisone injection into the area can be very helpful as well. If an injection is not an option for you, then oral medication to reduce the inflammation should also be considered.

There is a second possible cause for your pain and that is a displaced cuboid which as I have already stated is the bone just behind the fifth metatarsal bone. This is a much more difficult diagnosis to make as the displacement is so small, that it is difficult to pick up on x-ray or even CT scan. It is usually made on clinical grounds, meaning pressing on the cuboid leads to pain.

You mention you are going to see an orthotic specialist. You may want to hold off on that until you have an accurate diagnosis. A subluxed cuboid can be helped by an orthotic, but peroneal tendonitis will not be helped by an orthotic.

I would suggest seeing another podiatrist, one who is familiar with these two conditions.

Marc Mitnick DPM
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