What is the best management plan for a 51-year-old male patient with persistent left foot pain in the fifth metatarsal area after a month of injury, with no fractures on X-ray?

Management of Fifth Metatarsal Area Foot Pain

The most appropriate management for this 51-year-old male patient with persistent left foot pain in the fifth metatarsal area includes a walking boot for 4-6 weeks, NSAIDs for pain management, and activity modification, with follow-up imaging if symptoms persist beyond this period.

Assessment of Current Condition

Based on the clinical presentation, this patient appears to have a soft tissue injury in the fifth metatarsal area rather than a fracture, given:

• History of trauma ("stepped in a hole and the top of his foot popped")
• No fracture identified on X-ray
• Pain on light palpation
• Normal ROM, sensation, and capillary refill
• No visible swelling, bruising, or deformities

Management Plan

Immediate Interventions

1. Immobilization

   • Walking boot for 4-6 weeks is appropriate for fifth metatarsal area injuries 1
   • This provides stability and protection during the healing phase

2. Pain Management

   • NSAIDs are first-line treatment for metatarsal pain 2
   • The proposed regimen is appropriate:
     • Ibuprofen 600 mg TID PRN
     • Acetaminophen 325 mg 1-3 tablets TID PRN
     • Diclofenac cream BID PRN

3. Activity Modification

   • Bottom bunk memo for 90 days is reasonable to reduce stress on the foot
   • Avoid activities that exacerbate pain

Adjunctive Therapy

• Epsom salt foot bath can help reduce inflammation and pain
• Application of diclofenac cream after soaking may enhance penetration

Follow-Up Plan

If no improvement occurs after 6 weeks:

1. Advanced Imaging

   • MRI to evaluate for:
     • Stress fracture not visible on initial X-ray
     • Ligamentous injury
     • Tendon pathology

2. Specialist Referral

   • Referral to podiatric foot and ankle surgeon if symptoms persist beyond 6-8 weeks 2

Potential Diagnoses to Consider

1. Soft Tissue Injury

   • Sprain of the lateral foot ligaments
   • Peroneal tendon injury

2. Occult Fracture

   • Stress fracture of the fifth metatarsal
   • Jones fracture (fracture at the metaphyseal-diaphyseal junction)

3. Metatarsalgia

   • Pain and inflammation in the metatarsal region 3

Special Considerations

• If pain persists despite conservative treatment, consider:

  • Custom orthotic devices to redistribute pressure 4
  • Structural foot features may affect strain on the fifth metatarsal during walking 4
  • Physical therapy for strengthening and gait training

• For athletes or highly active individuals:

  • More aggressive management may be warranted
  • Zone 2 and 3 injuries (Jones fracture and proximal diaphyseal stress fractures) often require surgical fixation in active individuals 5

Common Pitfalls to Avoid

1. Missed Diagnosis

   • Fifth metatarsal fractures can be subtle on X-ray
   • Consider additional views if clinical suspicion remains high

2. Inadequate Immobilization

   • Patient compliance with walking boot is essential
   • Premature return to full weight-bearing activities

3. Overlooking Biomechanical Factors

   • Foot structure and gait mechanics can contribute to fifth metatarsal strain 4
   • Consider orthotic intervention if anatomical predisposition exists

The proposed treatment plan with walking boot, NSAIDs, and activity modification is appropriate for this patient's presentation and aligns with current guidelines for management of fifth metatarsal area pain.