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Fifth Metatarsal Apophysitis
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Contents
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
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
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
- Internal
- External
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ Iselin H. Wachstumsbeschwerden zur Zeit der knochem Entwicklung der Tubersositas metatarsi quinti. Deutsche Zeitschrift Chir 117:529–535, 1912.
- ↑ Mathieu, Thomas, et al. "Iselin's Disease: Case Study and Literature Review." J Sports Med Doping Stud 9.214 (2019): 2161-0673.
- ↑ Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 19421
- ↑ 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
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Last edited:
4 October 2022 12:44:54
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