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Fifth Metatarsal Apophysitis

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Other Names

  • Iselin's Disease
  • 5th Metatarsal Apophysitis
  • Fifth Metatarsal Apophysitis

Background

  • This page refers to apophysitis of the proximal Fifth metatarsal, eponymously termed Iselin's Disease (ID)

History

  • First described in 1912 by German physician Dr. Hans Iselin[1]

Epidemiology

  • Occurs in both male and female adolescents typically ages 8 to 14 (need citation)
  • Generally, there is a paucity of epidemiological data
    • A recent review identified only 17 cases in the literature[2]

Pathophysiology

  • General
    • Is a benign, painful traction apophysitis or osteochondrosis of the apophysis of the 5th metatarsal tuberosity
    • Exclusive to skeletally immature patients
    • Generally considered a self limited disorder
  • Often confused for
    • Fracture of the base of the fifth metatarsal

Etiology

  • Peroneus Brevis Tendon (PB Tendon)
    • Attaches on the tuberosity of the fifth metatarsal (apophysis)
    • Caused by repetitive microtrauma at the site of attachment
    • Can result in partial/complete avulsion of the apophysis and inflammation
  • Associated with athletics where repetitive motion occurs
    • Especially sports that stress the forefoot such as dance, ballet, skating
    • Sports which require jumping and running

Pathoanatomy

  • Fifth Metatarsal
    • Secondary ossification center appears as a small fleck oriented slightly oblique to the metatarsal shaft
    • Located on the lateral aspect of the tuberosity of the fifth metatarsal
    • Peroneus brevis inserts over this apophysis before skeletal maturity

Risk Factors

  • Sports
    • Dance
    • Ballet
    • Roller skating

Differential Diagnosis

Differential Diagnosis Foot Pain


Clinical Features

  • History
    • Athlete is typically 10 to 16 years old
    • Insidious onset with no history of trauma
    • Most common symptom is pain in the lateral part of the foot or around the base of the fifth metatarsal
    • Worse with activity and improves with rest
    • May have difficulty or pain with wearing shoes
    • Patients may have 3-6 months of symptoms before presentation
  • Physical Exam: Physical Exam Foot
    • Swelling and erythema over base of 5th metatarsal
    • Tenderness over base of 5th metatarsal tuberosity
    • Pain with resisted eversion and extreme plantar flexion/inversion
    • On gait exam, may favor medial side of foot
  • Special Tests

Evaluation

Oblique foot radiograph showing elevation, fragmentation and sclerosis of the apophysis with overlying soft tissue swelling consistent with 5th metatarsal apophysitis.[3]

Radiographs

  • Standard Radiographs Foot
    • Apophysis best seen on oblique view
  • Findings
    • Fragmentation
    • Widening or enlargement of the apophysis
    • Cystic changes around the apophysis
    • Widened chondro-osseous junction
  • Normal apophysis
    • Fleck of bone parallel to long axis of 5th metatarsal (≠ avulsion fracture),
    • Visible in girls (9-11), boys (11-14)

MRI

  • Findings[4]
    • Edema over the unfused apophysis
    • Mild to moderate marrow edema in the adjacent fifth metatarsal

Bone Scintigraphy

  • Generally not indicated or performed
  • Findings[4]
    • Increased uptake over the apophysis

Classification

  • N/A

Management

Nonoperative

  • Indications
    • All cases
  • Activity modification
    • Discontinue offending activity
    • Rest from sports
  • Immobilization/ weight bearing status
    • Cast immobilization if persistent pain despite other non-surgical management
    • May require crutches
  • Physical Therapy
    • Can begin after pain, tenderness are completely resolved
    • Stretching of peroneal and calf muscles
  • Ice Therapy
  • Foot Orthosis
    • A small lateral elevation or a lateral wedge ensures reduced stress on the peroneal muscles during daily activities
  • Prevention
    • Maintain calf, peroneal, and ankle flexibility and strength
    • Check shoe size during rapid periods of growth

Operative

  • Indications
    • Persistent pain despite exhaustive nonoperative treatment
    • Nonunion over the apophysis
    • Persistent widening of radiolucent lines after 3-6 months
  • Operative
    • Surgical excision

Rehab and Return to Play

Rehabilitation

  • Postoperative
    • Physical activity can be resumed 6-10 weeks after surgery

Return to Play

  • Pain typically resolves within 3-6 weeks of conservative treatment

Complications & Prognosis

Prognosis

  • General
    • Waxes and wanes but will resolve over time
    • Ossicles or bony prominence may persist but do not cause problems

Complications

  • Delayed return to sport
  • Inability to return to sport

See Also


References

  1. Iselin H. Wachstumsbeschwerden zur Zeit der knochem Entwicklung der Tubersositas metatarsi quinti. Deutsche Zeitschrift Chir 117:529–535, 1912.
  2. Mathieu, Thomas, et al. "Iselin's Disease: Case Study and Literature Review." J Sports Med Doping Stud 9.214 (2019): 2161-0673.
  3. Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 19421
  4. 4.0 4.1 Lehman RC, Gregg JR, Torg E (1986) Iselin’s disease. Am J Sports Med 14: 494–496.
Created by:
John Kiel on 30 June 2019 20:38:34
Last edited:
14 March 2022 10:25:30