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Sunday, August 18, 2019

5th Metatarsal Pain: Email Advice

Dear Dr. Blake,

I have been following your blog with great interest for a while as I've been dealing with a complicated injury to my plantar plate over my 5th metatarsal for more than 2 years. I was pleased to see that you are now accepting questions again, so I'm contacting you with the hope that you might give your perspective on my situation. Here are some facts about my injury: 
  • I'm a 33 y/o man, 160lbs. I began running in my early 20s and ran moderately (usually ~20 miles/week), though I've run more at times training for specific races (1 marathon, 4 half-marathons). 
  • I stopped running when I was 31 in May 2017 with a feeling of pain/fullness in my 5th metatarsal on my right foot with no memorable trauma. I was about running 15 miles a week and going to boot-camp-style exercise classes, getting back into it after a busy schedule and time off because of IT band issues in both legs. I immediately stopped running/jumping on the recommendation of my GP.
  • In September 2017, an MRI showed that I had a partial tear in my plantar plate. On the recommendation of my podiatrist, I began taping the toe down and continued to not run. 
  • In about February 2018, a second MRI confirmed the previous diagnosis. An orthotic insert was made by my podiatrist and I mostly refrained from running. I discontinued taping.
  • In May 2018, a sports medicine doctor discovered via x-ray that I in fact had rare sesamoid bones in my 5th metatarsal and that one of them was fractured (there was a development in the fracture between the X-rays taken in 2017 and 2018). This along with the partial tear was later confirmed by ultrasound imaging. 
  • Since this diagnosis I have added a Hapad to my orthotic insert to reduce pressure on my 5th metatarsal head. Other treatments I've tried have included wearing a surgical shoe (2 weeks) and full-ankle boot (about 20 days). 
  • Today, the pain is persistent, though more annoying than debilitating. I can often ignore it and I've even begun running in the last year some. I can usually run pain-free, but after building up for 3 to 4 weeks I often run into some type of setback. In general, my right ankle, arch, and achilles feel tight and often sore, and more recently in the last two weeks I started developing pain in my left metatarsal similar to the right one (I added a Hapad to my left insert and it's mostly taken care of it, though I still sometimes have fullness/aching or sharp pain). 
  • In the last year, I've seen two two surgeons (one orthopedic and another podiatric) and both were hesitant about performing surgery because of the location on the 5th metatarsal, though they both said they were willing to do it. My treatment plan at the moment is basically to wear orthotic inserts all the time and hope it goes away. Around the house I wear Hoka One One recovery sandals.
I apologize for the volume of information here--part of the desperation I feel from this injury is that I don't know where to start in thinking about what caused it or how to address it. A few specific questions might be helpful in addressing your feedback:
  1. My podiatrist and one of the surgeons both told me that they thought physical therapy wouldn't do much. However, I can't help but think something about my walking/running form and/or mobility is causing this. I've always been pigeon-toed--maybe after 10 years of moderate running (I'm 33) my ligaments just couldn't take it anymore? Do you think PT could help me now? 
  2. Related, I'm starting to question whether wearing the orthotic inserts with arch support at all times is really the right move here, especially given how weak and achy my right foot and ankle feel. Do you agree? 
  3. Anything you can do to make sense of these new symptoms I have in my left foot in the same area? Should I be treating this aggressively as a new injury? Or should I just keep doing what I'm doing with my right foot? 
Thank you for your time and please do let me know what information I could provide to give you a clearer picture of this situation. 

Best regards,

Dr. Blake's comment: Thank you so very much for emailing. The pigeon toe gait is supinatory, with excessive weight on the outside of your foot. The orthotics that you should be wearing are for off weighting the painful area and getting your weight centered on your foot (typically with more support on the lateral arch then the medial arch). The orthotic can be full length of soft materials with a float for the sore area (like a big cutout) or it can be typically plastic but with protective padding as much as allowed by shoe room and comfort. I always find that these tendencies to supinate or pronate happen on both feet, with one foot coming on first and being the worst side. Running shoes like Brooks Dyad or Glycerin or Saucony Triumph, or New Balance 1540 are typically good for supinators. If you can take a photo of the inserts from an old running shoe before orthotics that would help. Find a good PT or Running coach that watches gait and can help you decrease the stresses through the 5th metatarsal via gait changes. Downhills of course are the worse at picking on the 5th metatarsal. Even being conscious of running habits, like running with traffic is worse on the right 5th metatarsal than running against traffic due to the cant in the road. There are important muscle groups to strengthen if you are trying to supinate less-peroneals and medial hamstrings in particular and stretching iliotibial band and lateral hamstrings. Talk to the podiatrist about anti-supination (anti-5th metatarsal) prescription changes to your present prescription. Some circumferential KT or Rocktape over the metatarsals may help on both sides for a while, but pull the tape to lift up on the 5th metatarsal or counter clockwise on the right side as you look at it. You can experiment with using Dr. Jill's gel dancer's pads for the 5th metatarsal alone at times to get away from the orthotics to see how you feel. Here is a little horseshoe hole on the pad normally for the sesamoid but you are going to reverse the idea for the 5th metatarsal. I sure hope this helps somewhat. Rich

3 comments:

  1. Would long term treatment with Exogen ultrasound be indicated for the slow-healing sesamoid fracture?

    ReplyDelete
  2. https://healthylifefootclinic.com.au/

    ReplyDelete

Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.