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Fifth Metatarsal/Lateral Foot Pain following Fracture

Discussion in 'General Issues and Discussion Forum' started by Mark Russell, Jul 5, 2010.

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    50+ y/o female sustained Jones fracture to tuberosity of 5th met and fractures to base of 2,3,4 mets following RTA five years ago. Treated initially with closed reduction and plaster immobilisation. Review after 6 months revealed fibrous non-union of 5th met fracture which was treated with bone graft and internal fixation 12 months later. Increasing pain at fracture site and along the length of the 5th metatarsal necessitated removal of metalwork 1 year later, but this did not diminish pain, which has become intractible and unremitting and is graded at 8/10 at best. Pain is worse over healed fracture site, but extends both dorsally and plantarally from lateral heel to 5th MTPJ. Pain on ankle & subtalor mobilisation. Various diagnoses - Sudecks, CRPS, nociceptive and neuropathic pain - whilst x-rays show a healded fracture site and adjacent coalition, MRI shows 5th met BME/osteopenia. Currently wears BK aircast walking boot permenantly as movement in shoes/boots increases pain to intolerable levels. Discharged by orthopods, now under pain management and CBT. Advice re revision surgery, investigations, orthotic prescription, appreciated.

  2. G Flanagan

    G Flanagan Active Member

    Hi Mark,

    Sural nerve neurotmesis? although normally it would just be numb / parathesia.

    Maybe trying a diagnostic sural nerve block. Although the other thing to remember is that it will numb the lateral border anyway :bang:

    To be honest i'm clutching at straws, quite a complex patient. The osteopenia would go along with CRPS/RSD for which being under pain management is probably best. I think your in my area, is she under pain managment at the Vic, they are normally quite good.

    Sorry couldn't help more.
  3. Hello George

    I had thought she may have some nerve impingment from the coalition but there is no paresis or parasethsia and it is not transient - or hasn't been for the last 4 years. The problem I have with CRPS or Sudecks is that for all intents and purposes, it is simply a term that describes pain for which no-one has been able to diagnose a reason as yet. Much in the same way as pain from bone marrow oedema did before MRI came into being. Unfortunately, pain managment is not helping, even with lignocaine transdermal patches, tramadol and diamorphine, as well as TENS locally - she is still in a great deal of distress. I'll try her with a TCI and incorporate a lateral heel wedge with a 5th met cavity to off-load the painful area. But I would like to know what's causing the pain in the first place!

    Regards to all up north.

  4. Lab Guy

    Lab Guy Well-Known Member


    I am sure we have all seen patients that have sustained horrific trauma to their foot (like a lawnmower running over their foot ) and yet they make a fairly good recovery without developing RCPS.

    I think many times, something else is also going on mentally or emotionally that is disrupting their healing. I have read many books by Daniel Benor, MD,who is an internationally known Psychiatrist and developed WHEE (Wholistic Hybrid EFT and EMDR). You can go to his website and learn about it at: http://www.wholistichealingresearch.com/wheearticles.html. He has helped many people with dealing with severe pain and wrote a great book on WHEE to instruct people on how to use it.

    Most of us fail to be cognizant of the fact that the body is but one part that needs to be healed. If we are in need of healing mentally, emotionally, or spiritually, how can our injured body fully heal and come to balance? I think when we are dealing with RCPS we are dealing with a patient that has major issues else where.

    Questions need to be asked. Does the pain serve the patient in any way? Is there a subconscious reason why the patient wants to hold onto the pain? Is there an underlying emotional issue that is preventing healing?Is the underlying energy of the memory of the trauma that caused the accident causing her pain and delaying her recovery?

    We all have memories. All memories bring a feeling. Remember your first Christmas? As you remember it, how do you feel? The energy behind that memory is coming through and you are feeling it. It feels good.

    Now, bring a memory of a difficult event from the past to the front of your consciousness. With the mental memory in the front of your mind, how do you feel? You are feeling the difficult and distorted energy behind the memory and does not feel so good so you do as you have done before, lock it up deep inside of you.

    I think it is this energy that has not come to resolution that plays an important part in patients not healing well, developing chronic pain and other issues. When we can open the door to our emotional wounds and embrace the energy, learn from it and let it go, it is then that we can move forward. Therapists that specialize in EFT (Emotional Freedom Technique), WHEE, and the like should be considered for patients suffering with chronic pain IMO.

  5. I'm sure there's a role for CBT, EFT, WHEE and the likes, even though some of it is a bit fanciful for me. There should also be some consideration as to whether the pain or disability suits some other purpose with the patient and sufficient weight should be attached to this when contemplating the history and clinical examination. That said, in this case, it would appear that her pain, although disproportionate to the injury and management in the given timeframe, is consistent with some degree of local tissue damage and mechanical stress exerted on the area during normal ambulation. It is the disproportionate aspect that concerns me and whether I might be missing something more serious.

    Thanks again.

  6. jensglynne

    jensglynne Member


    Reading the case above reminds me of one of my own patients.

    In this case:

    17yo Female Professional Ballet Dancer 5th Met #. May 2009.
    Plaster cast by Hospital for 3/12 - non union after that amount of time plaster cast for a further 2/12. Resulted in union of # but still very painful 6-8/10 VAPS.
    Pt referred to Orthopedic Surgeon who suggested to start weight bearing gradually and basically go about her day-to-day life. This resulted in increased pain of 8-9/10 VAPS
    9 months on Pt presents to me with painful lateral aspect of her L foot upon weight bearing. 7-9/10 VAPS. X-ray reveals union of # site with some irregularities noted. No pain with vibration but palpation elicited considerable pain along the distal shaft of the 5th met.
    Cam walker for 8 weeks resulted in significant decrease in pain to 2-5/10 VAPS.
    Further xray has revealed complete union of fifth metatarsal without the irregularities noted before.

    This pt has been unable to return to dancing as a result of the pain, and also experiences a mild amount of pain on a day to day basis.

    I am also at a standstill as for what to do next.

    I have suggested further surgical consultation but stopping short of that Im unsure of how to continue.

    thought it was a very similar case...... INTERESTING



    I have advised pt begin weight bearing activities at a very slow gradual pace.
  7. musmed

    musmed Active Member

    Dear Mark et al.
    From reading this thread the patient definitely sounds like she has CRPS.
    To have CRPS they have to have 2 things. One is Hyperalgesia. This is pain that is greater than it should be
    Secondly is that the patient has allodynia. allodynia means other force. Here a sensation not matter how trivial is felt as greater than the stimuli would normally produce.

    The whole design is called a shift to the left in the threshold of pain production. The main therory regarding this phenomenon was postulated by Livingstone some years back. No one has had a better idea as far as I am aware.

    I noted that some think this is all a bit iffish.
    In the dorsal root ganglion there are ganglion cells that only have a dendrite and no axon. It is believed that these are triggered by some stimuli and never shut up complaining. This leads to the lamina 3 and 4 in the dorsal root ganglion to underg anatomical structural changes where the actual receptor sites on normal cells for chemicals such as ADP ATP Potassium glutamate endorphins and the list goes on, disappear and thus no amount of stimuli from the brain telling these cells to stop complaing basically falls on deaf ears.
    Studies in rats show that notrous oxide is produced indicating that the DNA in these cells has been activated.
    It is a terrible curse and can eventually take over the whole body as a total pain situation.
    Since there are no receptors present at the spinal cord level drug cannot work.

    CRPS has developed from a simple taking of blood for examination. About 10% of a males who have a hernia repair get it.

    Hope this helps
    Paul Conneely
    amongst other things, a pain management specialist
    I have enclosed a FDF of an MRI showing how bone looks in CRPS

    Attached Files:

    • CRPS.pdf
      File size:
      105.4 KB
  8. rommel04

    rommel04 Member

    Interesting case Mark, whats your view on the joint relationship between the cuboid and base of 5th and / or CC joint as been part of the package. Working with foot and ankle trauma for a number of years the obvious fracture issues take precedent but often the associated issues around the injury fall under the radar until the patient starts to mobilise more. Case in point relates to complications post os calcis fracture that can be discharged from the orthopaedic arena but major issues still exist re joint congruency in the STJ with a change in anterior / middle of posterior facets.

    You mention MR changes, has CT been performed to evaluate joint congruency in the relative surrounding joints. I mention CC joint as the symptoms spread across the base of the fifth to the lateral heel. CT may also allow a greater field of vision regarding the quality of bone union.

    Re treatment options, I understand that commercial footwear is an issue. Whenever I am faced with a Jones fracture once of the key features is to minimise the bending moment acting through the lateral column and look to utilise a commerical walking boot (mans due to wider last fitting) with a stiff sole plate, the stiffer the better.


  9. METaylor

    METaylor Active Member

    Dear Mark - the diagnoses are probably all mostly correct - neuropathic pain means pain in the nerves, and sudeck's and CRPS are the same - both involve the autonomic nerves and a self perpetuating reflex back to the central ganglion. The Europeans have a treatment for this called neural therapy, which involves injections of local anaesthetics to the area where the disturbance began, ie to the fracture site. Just tiny 0.1-0.5ml 1% lignocaine to various spots in the whole painful area, which will be larger than just the fracture site. You'll need to repeat it when the pain comes back. If the pain relief the first time lasts longer than 20 hours it will gradually get longer and longer (usually approximately doubling) until the area stays functional and pain free without further treatment. One source of info on this is Dr Robert Kidd's website and book http://www.neuraltherapybook.com/ Another brief intro is http://www.whale.to/w/neural.html. I believe that anaesthetists sometimes put local anaesthetics into a painful scar - its a pretty simple technique, what have you (and she) got to lose. I think it works because the LA strongly polarises cell membranes and therefore they become healthier and can resume normal functions, but it takes a few times before it fully corrects. My first patient only took 2 treatments - she had had pain in the lung for a year since a GB op. 2 lots of LA to the scar and the pain was gone. I've done it hundreds of times since - mostly very effective. A 15yr old boy with excrutiating pain in the scrotum and diarrhoea for 2 years since a testes removed for missed torsion, took 6 treatments and is still pain free a year later. Give it a go.
  10. Thanks for the replies - much appreciated. Regarding the midfoot joint relationships, I have asked for some weightbearing radiographs as the previous plates have all been done nonweightbearing. The pain is certainly localised and there's an element of allodynia over the surgical scar, fracture site and dorsum of foot, and whilst Sudecks/CRPS is a strong contender, I still want to exclude nerve impingment from the coalition and/or bone marrow oedema as the primary source of the pain. I haven't undertaken any neural therapy, but would be happy to try anything the relieve these distressing symptoms, but I'm not sure the patient would welcome anymore invasive Rx given the past history - especially where a successful outcome may be marginal. Any thoughts on performing a sural neurectomy posterior to the injured tissues?
  11. Lab Guy

    Lab Guy Well-Known Member


    I have performed a fairs number of Sural nerve resections for Chronic pain over the years and had very good results and with no adverse complications.

    Prior to the surgery, I would block the sural nerve first with long acting Bupivicane and Epi behind the ankle and have the patient ambulate for 24 hrs to see how much the pain decreased. If there was a substantial pain reduction then I would resect the nerve. To prevent irritation at the end of the nerve/stump neuroma, I would excise a section from mid calf http://functionalanatomyseminars.files.wordpress.com/2009/11/sural-nerve.jpg, however most surgeons remove a section in the posterior lateral ankle. I never had any complications from excision of portion of Sural nerve and patient was left with sensory loss only and that was clearly discussed pre-op.

    Very tough case, there are no black and white answers.

  12. musmed

    musmed Active Member

    Dear Mark
    By definitions set down in 1993 by the international study for pain, there is no such thing as Sudek's atrophy.

    CRPS is not 100% related to the sympathetic chain. It is estimated to be only 50%
    And thus Dr. Kidd's explanation does not work in these non sympathetic mediated CRPS.

    There are studies relating to the arm. Here Guanethidine injections were put into the cervical ganglion. The patients with sympathetically mediated CRPS last their pain.
    These same souls had normal saline injected into the same ganglions and these also lost their pain. So what is the mechanism?

    Remember that chronic pain is just a date time diagnosis of havin a pain. Chronic is different from acute by the fact that if one has a pain for longer that 12 weeks, that pain is defined as chronic.

    CRPS is a spinal cord disease as well as a possible neuromal peripheral disease.

    Please remember that doing any treatment can accelerate their condition and make them worse.
    If one was to do anything, get a signed consent form.

    It is simply a terrible disease and in most cases impossible to treat.
    Paul Conneely
  13. METaylor

    METaylor Active Member

    Who cares what it's called or which part of the nervous system is involved. In 10 years time it will be called something different and our understanding will have also changed. The important thing is that various types of chronic pain can be treated by injections of local anaesthetic repeated a few times until it no longer comes back. How do you know it doesn't work if you haven't tried it. I have effectively treated CRPS with this technique.
  14. musmed

    musmed Active Member

    I do.

    How can you treat something with a pathology that is not known?

    Paul Conneely
  15. METaylor

    METaylor Active Member

    We don't know what causes most headaches and we can treat them effectively, and we were using aspirin effectively for decades before we knew how that worked.
  16. Thanks, Steven. Will take this into consideration.

    Best wishes


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