5th metatarsal burning pain

pt with inversion injury, burning 5th metatarsal pain with warmth, pain increased with vibratory sense, initial xrays neg, recent bone scan neg, active DF, PF and eversion increase pain, all muscles strong with resisted eversion increasing pain...any thoughts? the burning/warmth pain sounds nerve related, not sure where to go from here.
Many Thanks.
J

When did your patient have thier x-rays? I only ask because I had a patient that had a Jones fracture (of the head of the 5th Met) and initially it was missed by the club doctor and at A&E, it wasn't getting better so he went back to A&E and they found a break.

If you are not happy with your findings always get it checked out in my opinion.

Another thing to try is that when you are doing the passive movements look at your hand positions, are you applying pressure on the sore area, if this is possible change your grip and see the outcome

I see two possibilities, assuming the investigations done have cleared a bony cause.

The most obvious one is along with the inversion MOI some trauma was sustained to the peronius brevis tendon itself. It could have sustained a partial tear that has not fully healed yet. You mention X-rays and bone scan, but has there been any attempt to do an ultrasound scan of the area (I don't know how easy this would be to get a viable picture as the area is relatively small). An MRI would clarify this possibility further, although I suspect their symptoms are not of the severity to warrant that referral at this time. Alternately, I have seen people who subsequent to an ankle inversion sprain have developed a tendonitis/symptomatic tendonosis in the peroneii. I suspect this is due to overuse of these muscles while compensating for the ligamentous laxity. Typically this has presented posterior to the lateral malleolus, but I can't see any reason why it couldn't happen at the tendon's insertion.

I think both possibilities would be managed similarly. Settle down the inflammatory process, ensure the foot mechanics are good (or well supported) and re-build the strength/control when less irritable.

The other possibility, along the lines of your "nerve" theory, would be some minor trauma to the sural or lateral plantar nerve. This could easily have happenned with the initial inversion MOI, although I suspect the symptoms would be a little more diffuse than they are described. You will need to do some specific neurodynamic testing for this to rule in/rule out certain peripheral nerves. If you are unsure about how to do this, consult with a colleague that is a musculoskeletal/manual specialization, or someone who has taken at list one the the NOI Group's nervous system courses. Remember that you can get some false positives with neurodynamic testing if you don't take into account that you are also stressing other soft tissue (tendon, ligament, etc.) structures with the various positions. You need to do it all, write down the details as you go, then put it all together in the end. Good luck!

Let me recommend a simple technique that has done wonders with similar pains. Place a met-pad or met-bar millimeters behind the metatarsals heads. This will allow two things as full weight bearing is placed on the metarsals. First it will displaced weight bearing forces as the foot splays; second weight bearing forces will be diminished at area of pain allowing faster healing process. MAKE sure what you do in one foot you do on the other. DO NOT place only one met pad or met bar in only one foot....unless you want the patient to come back with other orthopedic problems this will cause.
regards