Iselin’s Disease

Iselin’s disease is a relatively uncommon orthopedic condition that affects growing children, particularly those engaged in high-impact sports or physical activities. Named after Dr. Hans Iselin, who first described the condition, Iselin’s disease is an apophysitis, an inflammation where a tendon attaches to a growth plate, affecting the base of the fifth metatarsal bone of the foot. This area, also known as the tuberosity of the fifth metatarsal, serves as the insertion point for the peroneus brevis tendon. Iselin’s disease primarily occurs in children between the ages of 8 and 14, during periods of rapid growth when the bones, muscles, and tendons are developing at different rates (1).

Though not considered a serious condition, Iselin’s disease can cause significant discomfort and limit mobility if not diagnosed and managed early. Fortunately, with appropriate care and rest, the prognosis is excellent, and long-term complications are rare (1).

Symptoms

The hallmark symptom of Iselin’s disease is pain along the outer edge of the foot, especially at the base of the fifth metatarsal. This pain may vary in intensity and is often aggravated by physical activity such as running, jumping, or playing sports. Other associated symptoms include (2):

• Tenderness and swelling at the outer midfoot
• A limp or reluctance to bear weight on the affected foot
• Pain that worsens with pressure on the foot or tight-fitting shoes
• Redness or warmth over the affected area in some cases (2).

The symptoms typically develop gradually and may be misinterpreted as a simple sprain or overuse injury. However, persistent pain localized to the lateral aspect of the foot should prompt further evaluation (3).

Causes

Iselin’s disease results from repetitive traction or pulling of the peroneus brevis tendon on the growth plate at the base of the fifth metatarsal. During growth spurts, the bones grow faster than the tendons can adapt, leading to increased tension at tendon attachment sites. Activities that involve running, cutting, or jumping, particularly on hard surfaces, place additional stress on this area, leading to microtrauma, inflammation, and ultimately pain (1).

This overuse-related inflammation disrupts the normal development of the apophysis, resulting in the characteristic symptoms of Iselin’s disease (1).

Risk Factors

Several factors increase a child’s risk of developing Iselin’s disease:

1. Age and Growth Spurts: Most cases occur in children aged 8 to 14 years, when growth plates are still open and the musculoskeletal system is undergoing rapid changes.
2. High-impact Sports: Participation in activities such as soccer, basketball, gymnastics, and track increases repetitive stress on the foot.
3. Footwear: Poorly fitting or unsupportive shoes can increase the strain on the lateral foot.
4. Biomechanics: Foot abnormalities like high arches or improper gait may alter the distribution of forces, placing extra tension on the peroneus brevis tendon.
5. Previous Injury: A history of lateral foot injuries may predispose a child to Iselin’s disease due to residual instability or weakness.

Diagnosis

Diagnosis of Iselin’s disease is largely clinical, based on a detailed history and physical examination. The healthcare provider will evaluate the child’s symptoms, activity level, and physical findings such as tenderness at the fifth metatarsal base (2).

Imaging may be used to confirm the diagnosis and rule out other conditions:

• X-ray: This is the most commonly used imaging tool. They may reveal fragmentation or widening at the apophysis of the fifth metatarsal, a key sign of the disease. It’s important to differentiate these findings from normal growth plate development or an acute fracture.
• MRI or Ultrasound: Rarely needed but may be used if symptoms are severe or if other soft tissue injuries are suspected (2).

Treatment Options

The treatment for Iselin’s disease is conservative, focusing on rest and reducing inflammation. The following strategies are commonly recommended (3):

1. Activity Modification: The child should avoid aggravating activities such as sports until the pain subsides. Rest is essential for healing.
2. Ice Therapy: Applying ice packs to the affected area for 15-20 minutes several times a day can help reduce swelling and pain.
3. Footwear Modification: Wearing supportive shoes with good arch support and cushioning can relieve pressure on the fifth metatarsal.
4. Orthotic Devices: Shoe inserts or lateral wedges may help redistribute weight and reduce stress on the foot.
5. Pain Management: Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen may be used to manage discomfort (3).
6. Immobilization: In cases of severe pain, a walking boot or short leg cast may be prescribed temporarily to immobilize the foot and promote healing.
7. Physical Therapy: Once the pain subsides, gentle stretching and strengthening exercises may be introduced to restore function and prevent recurrence.

Surgery is rarely, if ever, needed in the treatment of Iselin’s disease (3).

Living With or Prevention

Living with Iselin’s disease involves a commitment to rest, proper footwear, and gradual return to activity. The condition is self-limiting, and most children recover fully within a few weeks to months with appropriate management (2).

To help prevent Iselin’s disease or reduce the risk of recurrence:

• Encourage gradual increases in activity levels, especially during periods of rapid growth.
• Ensure children wear properly fitting, supportive footwear suited to their sport or activity.
• Incorporate stretching and strengthening exercises into the child’s routine to maintain flexibility and muscle balance.
• Educate children to report foot pain early and avoid “pushing through” discomfort  (1).

Once healing is complete and symptoms have resolved, children can safely return to their regular sports and activities under medical guidance (2).

Reference

1. Kishan TV, Mekala A, Bonala N, Sri Pavani B. Iselin’s disease: Traction apophysitis of the fifth metatarsal base, a rare cause of lateral foot pain. Med J Armed Forces India. 2016 Jul;72(3):299-301. doi: 10.1016/j.mjafi.2015.06.015. Epub 2015 Aug 31. PMID: 27546974; PMCID: PMC4982981.
2. Aljabri NK, Alhassani TH, Labban AA, Alsawaf AH, Alnofeay KA. Iselin Disease With a Rare Presentation in an Elderly Patient: A Case Report. Cureus. 2023 Jan 18;15(1):e33922. doi: 10.7759/cureus.33922. PMID: 36819335; PMCID: PMC9936917.
3. Deniz G, Kose O, Guneri B, Duygun F. Traction apophysitis of the fifth metatarsal base in a child: Iselin’s disease. BMJ Case Rep. 2014 May 15;2014:bcr2014204687. doi: 10.1136/bcr-2014-204687. PMID: 24832713; PMCID: PMC4025211.