Pain in the foot of a child or adolescent can be dismissed as one of the ‘growing pains’, however in some cases the cause may be more specific – and more treatable – than that. Iselin’s disease in the foot is one condition which is often ignored solely on the basis that nobody has heard of it. The pain affects the lateral aspect of the foot, in otherwise healthy, active adolescents aged between 8 and 13 years, and can significantly affect the child’s participation in sports and the physical and educational activities of day to day life.
Knowing what the condition is and what its implications are can make a difference for families searching for relief from pain.
What Is Iselin’s Disease?
Iselin’s disease in the foot is a pathology of the growth plate apophysis at the base of the fifth metatarsal. The apophysis is a secondary ossification centre on the lateral border of the foot found just inferior to the fifth toe. It is a cartilaginous growth plate that has not yet ossified, or turned into hardened bone.
The cartilage is the weakest part of the bone, and it is this part that gets stressed by the traction force of the peroneus brevis tendon that inserts into the apophysis. Inflammation and irritation occurs at the site, in an effect known as traction apophysitis.
Why It Mainly Affects Children and Adolescents
Adults cannot develop Iselin’s as the epiphysis is fused. Once the apophysis closes – typically around 16 for girls and 17 for boys – it fuses to the tibia. It becomes one and becomes bone, thus removing the vulnerable point.
This is why the condition is almost entirely pediatric. Children taking part in high-energy sports are most at risk although it can occur in children that are less active during periods of rapid growth.
Signs and Symptoms to Watch For
The most consistent presenting symptom is pain over the lateral border of the foot which is approximately where the foot begins to turn towards the small toe. The pain is often dull and aching during activity and more sharp in the early period afterwards. Swelling over the bump is often apparent and direct palpation is tender.
Children often walk on the medial side of the foot to offload the pressure which may cause some secondary pain in the knee or hip.
How Iselin’s Disease Feels Day to Day
Patients will commonly complain of an annoying ache that exacerbates with activity, such as running, jumping and cutting in sports. Certain types of shoes, such as cleats, flat soled shoes or tight shoes may aggravate the problem. Children may have morning stiffness that improves after several minutes of walking, and returns with activity.
Easy activities, such as quick walking between classrooms or climbing stairs, may become sore for this normal, active child.
When Symptoms Might Not Be “Just Growing Pains”
Signs of more sinister pathology that require urgent referral are: rapid development of pain following a single traumatic incident- such as an ankle roll-it is unlikely to be apophysitis, in the absence of a fracture; pain that is not relieved at all by rest; spreading swelling; Ecchymosis around the lateral foot; Numbness or Paraesthesia or a marked change in coloration of the skin should all raise the suspicion of a significant problem.
Why Iselin’s Disease Happens: Causes and Risk Factors
What essentially creates Iselin’s disease is the repetative mechanical load on a growing immature physis. The peroneus brevis lies along the lateral side of the lower leg, inserting at the base of the fifth metatarsal. With each push off, turn or rebound of the foot, that tendon pulls on the apophysis.
During rapid growth, this pressure can cause inflammation and micro injury.
Common Sports and Activities Linked to Iselin’s Disease
Football, however, seems to be the most commonly thought of sport, with all the continuous side-to-side jumping, kicking, landing and turning. Basketball, gymnastics, dancing are common pointers of this syndrome and if you think about it, even cross-country running over rough ground can provoke this condition. If repetitive loading of the feet and/or sideways stress of the feet occurs in any activity, this syndrome can arise.
Athletes who participate in year-round daily training without having enough time for rest are especially prone.
Foot Structure, Growth Spurts and Other Influences
A tight calf muscle would mean an increase in tension force over the peroneus brevis tendon, thus increasing the workload for children with less ankle flexibility. A high-arched foot would involve increased loading through the lateral aspect of the foot, whereas a flat foot could also change gait in a way that would influence the same area in a different manner. Growth was cited as a primary reason, as it involves a rapid increase in speed of lengthening of the bones whilst the muscles and tendons are still taking longer to lengthen: putting children at a high risk of injury for a short period of time.
Diagnosis: How Doctors Tell It Apart from a Fracture
Getting the diagnosis correct is important because the clinical presentation of an avulsion injury of the base of the fifth metatarsal is similar to that of other conditions but it needs to be managed differently. The doctor will ask about the history of when pain was first experienced, what activity was undertaken prior to pain and whether there was any sort of event that could have caused injury. The examination looks to confirm the location of the pain clinically and to observe the way the patient walks.
What to Expect at the Clinic or Hospital
X-ray is requested in the first instance to exclude fracture. On view, the appearance of the growth plate itself can be irregular or fragmented which is normal in Iselin’s disease and is not a sign of a fracture. Like any normal x-ray in an experienced clinician the appearance is interpreted in conjunction with the clinical findings.
Sometimes, an MRI is also requested if the diagnosis remains doubtful or if the patient has very severe symptoms but this is not the routine response.
Conditions That Can Mimic Iselin’s Disease
A Jones fracture is located slightly farther down the fifth metatarsal and takes longer to heal. Peroneal tendinopathy, cuboid syndrome and lateral ankle sprains may cause pain in the general area. With a careful physical exam and radiographs, the pathology can normally be distinguished by a specialist without trouble.
Treatment Options for Iselin’s Disease in the Foot
Fortunately, Iselin’s disease in the foot usually responds to conservative therapy. Very rarely are surgical procedures necessary. The mainstays of treatment involve minimizing the mechanical stress on the epiphysis while keeping the child as comfortable and as fit as possible.
Activity Modification, Bracing and Rehabilitation
Most children require an active program of taking a break from the activities that are producing the pain (but not complete bed rest). If the pain is significant then a cast or walking boot for between 2-6 weeks should be applied to provide added off-loading. Rehabilitation including calf stretching, peroneal strengthening and balance retraining in order to return the athlete to full function and decrease the risk of recurrence.
Medications, Footwear and Simple Home Strategies
Over-the-counter anti-inflammatory agents such as ibuprofen are helpful to reduce pain in the short term when used appropriately with parental supervision. In the long term, conversion to supportive, cushioned footwear with a slight heel-rise can unload the peroneus brevis. Ice in 15 to 20-minute intervals post-activity can be used as an easy inexpensive method to reduce swelling.
At rest, a small lateral heel wedge can be used within the shoe to reduce load to the lateral foot.
Long-Term Outlook, Recovery Time and Prevention Tips
Prognosis is really very good for Iselin’s disease. Children’s generally get better within 6-8 weeks of conservative treatment and the condition is rectified once the growth plate fuses, with no structural effects if managed reasonably well.
Returning Safely to Sports and Daily Activities
Reintroduction of sport should be based on the completion of a pain guided program, rather than a pre-determined timeframe. Generally a child who can walk fast (high walking speed) pain free, walk and jog pain free without a limp, and do some low load sport specific movements without pain is ready to increase their training load. Returning too rapidly is the most common cause for recurrence of symptoms.
Subtle signs of compensation such as an asymmetry of load bearing on one leg can be missed by the untrained eye.
Preventing Future Foot Pain in Growing Children
A handful of simple exercises can make a enormous difference in preventing another flare up or an initial occurrence of Iselin’s disease. Consistent stretching of the calf muscle groups can keep the strain on the tendons in check. Providing a gradual increase in athletic activity, especially during periods of rapid physical development, allows the body to adjust.
Interchanging types of shoes, as well as making sure not to wear out shoes too quickly, is also beneficial. However, perhaps the most essential thing a parent or coach can do to avoid the problem altogether is to listen honestly to what a child has to say about how much pain he or she is experiencing during times of rapid growth.