What is the appropriate workup for a patient presenting with pain in their fifth toe?

Workup for Pain in Pinky Toe

The appropriate initial workup for a patient presenting with pain in the fifth toe should begin with radiography of the foot, which is the recommended first imaging study for evaluating toe pain. 1

Initial Clinical Assessment

• Determine if the pain is acute (traumatic) or chronic in nature, as this will guide the diagnostic approach 1, 2
• Evaluate for point tenderness, swelling, deformity, or skin changes in the affected toe 1
• Assess weight-bearing ability and gait pattern 1
• Note any history of trauma, even minor, as this could indicate a fracture 1
• Consider systemic conditions that may manifest with toe pain (e.g., inflammatory arthropathies, neuropathies) 3

Imaging Studies

For Acute Pain:

• Radiography (X-ray) of the foot is the recommended first imaging study for suspected toe fractures or dislocations 1

  • Standard three-view study (anteroposterior, oblique, and lateral) is typically sufficient 1
  • Although Ottawa rules primarily address midfoot injuries, radiographs are appropriate when a toe fracture is suspected 1
  • Sensitivity for detecting toe fractures ranges from 80-100% 1

• If radiographs are negative but clinical suspicion remains high:

  • Consider advanced imaging based on clinical findings 1
  • MRI may be indicated if soft tissue injury is suspected 1
  • CT may be useful for complex fractures or when radiographs are inconclusive 1

For Chronic Pain:

• Radiography (X-ray) of the foot remains the recommended initial imaging study 1

  • Useful for detecting osteoarthritis, stress fractures, and other bony abnormalities 1
  • Can help exclude other causes of forefoot pain such as Freiberg's infraction 1

• If radiographs are negative or inconclusive:

  • MRI may be indicated for suspected soft tissue pathology 1
  • Ultrasound may be useful for Morton's neuroma, intermetatarsal bursitis, or plantar plate tears 1

Common Causes of Fifth Toe Pain

Acute Causes:

• Fracture (traumatic or stress) 2
• Dislocation 2
• Contusion 2
• Foreign body 1

Chronic Causes:

• Metatarsalgia 2
• Bunionette (tailor's bunion) 2
• Lesser toe deformities (hammer toe, claw toe) 2
• Morton's neuroma (though more common between 3rd and 4th toes) 4
• Intermetatarsal bursitis 1

Management Considerations

• Initial treatment for most acute toe injuries includes rest, ice, compression, and elevation (RICE) 2
• For fractures, buddy taping to adjacent toe may be sufficient for stable injuries 2
• For chronic conditions, appropriate footwear with adequate width is essential 5
• Orthotic devices may help redistribute pressure and reduce pain 5
• NSAIDs may be used for pain management and reducing inflammation 5

When to Consider Referral

• Displaced fractures requiring reduction 2
• Open fractures or dislocations 1
• Pain persisting despite 6-8 weeks of appropriate conservative treatment 5
• Suspicion of systemic disease causing toe pain 3
• Need for advanced imaging or diagnostic testing 5

Common Pitfalls

• Overlooking small avulsion fractures on radiographs 1
• Failing to consider systemic causes of toe pain 3
• Not obtaining weightbearing views when indicated 1
• Underestimating the impact of proper footwear on symptom management 5
• Missing foreign bodies in cases of penetrating trauma 1