Trouble Afoot
Answer: B
This boy is suffering from Iselin’s disease, an apophysitis from chronic traction on the base of the 5th metatarsal, associated with inversion stresses and repetitive microtrauma. Symptoms are worse with weight bearing and inversion stresses. On exam, there is often local swelling and/or tenderness; pain can be elicited by eversion against resistance and plantar flexion (A, C, D).
Although plain films are not necessary to make the diagnosis, they may be needed to rule out other conditions with overlapping presentations, most notably Jones fracture and dancer’s fracture.
A Jones fracture is a transverse fracture of the 5th metatarsal base no more than 1.5 cm distal to the tuberosity. The mechanism of action is typically significant adduction of the forefoot with the ankle in plantar flexion. Jones fractures are prone to non-union – after casting, strict non-weight-bearing is essential; surgery is often required if there is poor healing after 6-8 weeks.
A dancer’s fracture (also called pseudo-Jones fracture) is the most common fracture in this location (base of the 5th metatarsal). Most commonly extra-articular, most do well with either a hard-sole cast shoe or a short leg weight bearing cast for 4-6 weeks; surgery is rarely needed.
Below are radiographs of adults with Jones fracture (left) and dancer’s fracture (right). Note that both fractures show obscuring of the metatarsal-cuboid joint. Recall that this does not occur in Iselin’s apophysitis (B).
This boy is suffering from Iselin’s disease, an apophysitis from chronic traction on the base of the 5th metatarsal, associated with inversion stresses and repetitive microtrauma. Symptoms are worse with weight bearing and inversion stresses. On exam, there is often local swelling and/or tenderness; pain can be elicited by eversion against resistance and plantar flexion (A, C, D).
Although plain films are not necessary to make the diagnosis, they may be needed to rule out other conditions with overlapping presentations, most notably Jones fracture and dancer’s fracture.
A Jones fracture is a transverse fracture of the 5th metatarsal base no more than 1.5 cm distal to the tuberosity. The mechanism of action is typically significant adduction of the forefoot with the ankle in plantar flexion. Jones fractures are prone to non-union – after casting, strict non-weight-bearing is essential; surgery is often required if there is poor healing after 6-8 weeks.
A dancer’s fracture (also called pseudo-Jones fracture) is the most common fracture in this location (base of the 5th metatarsal). Most commonly extra-articular, most do well with either a hard-sole cast shoe or a short leg weight bearing cast for 4-6 weeks; surgery is rarely needed.
Below are radiographs of adults with Jones fracture (left) and dancer’s fracture (right). Note that both fractures show obscuring of the metatarsal-cuboid joint. Recall that this does not occur in Iselin’s apophysitis (B).
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Accessory ossicles may be present (e.g. os vesalanium at the base of the 5th metatarsal), but these are recognized by an intact cortex of a non-displaced small structure, often symmetrical and in a stereotypical site.
Treatment of Iselin’s disease includes rest, weight bearing as tolerated, and addressing the acute inflammation: NSAIDs, ice for 10-15 minutes every 2-3 hours for the first few days. Healing typically takes 1-2 months; children should not “play through the pain”, or risk non-healing and chronic pain. Iselin’s disease is often self-limiting; only very rarely in chronic forms is surgery necessary.
Other common sites of apophysitis:
Osgood-Schlatter disease – tibial tuberosity
Sinding Larsen-Johansson disease – inferior patellar pole
Sever’s disease – calcaneus
References
Hwang C, Sims L, Wang NE. Common Overuse of Injuries of the Pediatric Lower Extremity. Pediatric Emergency Medicine Reports. 2013; 18(3)
Wilson JC, Rodenberg RE. Apophysitis of the lower extremities. Contemporary Pediatrics. 2011.
Other common sites of apophysitis:
Osgood-Schlatter disease – tibial tuberosity
Sinding Larsen-Johansson disease – inferior patellar pole
Sever’s disease – calcaneus
References
Hwang C, Sims L, Wang NE. Common Overuse of Injuries of the Pediatric Lower Extremity. Pediatric Emergency Medicine Reports. 2013; 18(3)
Wilson JC, Rodenberg RE. Apophysitis of the lower extremities. Contemporary Pediatrics. 2011.