Management of Iselin’s disease in an 11-year-old female soccer player:
A case report
Ryan J. Brandt DC, FACO1
1Private practice Coon Rapids, MN
Published: March 2017
Journal of the Academy of Chiropractic Orthopedists
March 2017, Volume 14, Issue 1
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2017 Brandt and the Academy of Chiropractic Orthopedists.
Introduction: This is a case study reporting injury to the lateral side of the right foot and treatment of an 11-year-old female soccer player.
Case presentation: She presented with a 2-week history of right lateral foot pain. The complaint was progressively worsening and effecting her athletic activities.
Management and outcome: She was seen twice a week for two weeks with treatments consisting of in office low wattage ultrasound after it was determined there was no fracture or ligament disruption. Athletic taping of the foot and arch was performed, and after two weeks soft arch supports were placed in her every day and sports shoes. The condition was substantially resolved within two months.
Discussion: Foot pain in running athletes is not uncommon. The concern was to differentiate this presentation from a stress fracture, Jones’ fracture, apophysitis or joint sprain. It was determined this more than likely was Iselin’s disease of the right fifth metatarsal head.
Keywords: Iselin’s disease, lower extremity pain, repetitive stress injury foot, foot pain in young adults, orthotics
Iselin’s disease is an uncommon condition that can be very confusing and difficult to distinguish from fracture, sprain or traction apophysitis. Iselin’s is consistent with a traction apophysitis (1,2) Plain film imaging studies are helpful in ruling out fracture, disruption of the apophysis and/or other pathology. Young athletes are prone to foot injuries from running, jumping as well as sudden stops and starts. Improper footwear may contribute to global or localized foot pain as discernment of a proper fit may be difficult (3). The literature is scarce regarding Iselin’s disease but it is felt by Barrett et al this may be due to the complex pathology of the proximal fifth metatarsal leading to the misdiagnosis of Iselin’s disease. (4) The purpose of this paper is to make the clinician aware of the possibilities of foot pain over the 5th metatarsal to consider the pain being caused by Iselin’s disease.
An 11-year-old female soccer player presented to a private chiropractic orthopedic office with a 2-week history of increasing insidious right lateral foot pain. These symptoms were provoked with running, jumping and sudden starting and stopping during the course of athletic activity. Her pain was more pronounced in the hours following the sporting activity. The patient was asked to rate her pain while walking, at rest or when running using a 0 to 10 scale. Her pain when walking was 2-4/10, it was 0-1/10 resting and running was 6-7/10. Her parents reported that her complaints were of mild pain initially but have been getting progressively worse. It seemed to be exacerbated with the introduction of basketball and her tight basketball shoes.
The patient has a history of successful treatment of Sever’s disease in both heels and bilateral knee tendinopathy over the past 12-18 months. Sever’s was concluded with examination and review of foot x-rays by a chiropractic radiologist. The tendinopathy was treated with ultrasound, Kinesio-tape and home care consisting of ice applications. She responded well to the treatment. She plays soccer both indoor and outdoor the year-round as well as basketball and participates in swimming and golf seasonally. Her parents report very little downtime from her sport.
Her examination revealed active and passive full bilateral ankle range of motion. Her dorsal pedis and posterior tibial pulses were firm and equal bilaterally. No swelling or discoloration was noted in her feet. Her skin was normal temperature to touch and good muscle tone was noted in the lower leg muscles. She had bilateral Morton’s toes and a positive bilateral Helbing’s sign. Bilateral pes planus and pronation was observed. Slight genu valgum was also observed. No gait abnormalities were present on observation. She had marked tenderness on palpation at the base of the right fifth metatarsal but not on the left. This included the proximal joint and into the upper one-third of the metatarsal. She had mild discomfort in the area of chief complaint when standing on her toes in this area. Manual compression of the forefoot was not significantly provocative.
Bilateral foot x-rays were ordered. The clinical findings met the standards of Ottawa rules for plain film radiographs of the knee, ankle and foot. This included pain at the base fifth metatarsal (5). The radiographs were unremarkable for fracture, dislocation or gross osseous pathology. Right compared to the left fifth metatarsal presented an identical appearance. (Figures 1 & 2)
Figure1. Oblique radiograph of the right foot
Figure 2. Lateral radiograph views of the left foot
Treatment included in office twice-weekly therapeutic ultrasound at 0.5 W underwater and pulsed at 50% for five minutes over the fifth metatarsal area, (6) passive mobilization to the forefoot was performed. Patient was instructed to ice of 2-4 times a day 3-weeks. Supportive athletic taping was applied to the arch for support. Stretching of the calf muscles was utilized daily at home and prior to the active sport participation. Basketball competition and practice was eliminated until the condition resolved. She continued with soccer 2-3 times a week with rest between practice and games. Soft arch supports from Spenco© were placed in both athletic shoes (7). She presented with lateral foot pain. Her father reported that within 2-months after the onset of pain and treatment there was no pain with her normal activities of daily living and only slight soreness reported with running, jumping and rollerblading. A follow-up three months later from the onset of pain to the office, she reported no complaints and no pain on evaluation. She was participating without any foot problems playing soccer. Her parents reported that they observed she was playing with no indication of foot pain or other adverse reactions to the sudden stopping, starting and kicking.
Injuries to young athletes are a significant concern to parents. The complications of such injuries may affect biomechanics of the joint but also a cascading effect of biomechanical joint problems above and below an injured area. The clinical features of Iselin’s include focal pain over the proximal head of the 5th metatarsal. It may be a sudden onset or insidious. This case was a gradual onset from soccer and basketball. Improperly fitting shoes with sudden stops and starts contributed to this condition in the authors opinion. Treatment was successful in the office, but having parental understanding and cooperation is essential. They had the understanding that continuing to play both sports and the poor shoes contributed to the condition. New shoes were obtained during the period of treatment. It is important in the initial stages of injury that the clinician be as accurate as possible and staging initial and future treatment. Clinical experience, algorithms and guidelines may be helpful.
Foot pain in the young athlete is not uncommon. Iselin’s disease was considered the most likely differential on this case due to the focal 5th metatarsal head pain. There are not many cases reported in the literature but it may be more common than reported as cases may be misdiagnosed. (4)
There is no certain manner to definitively confirm the diagnosis of Iselin’s disease from that of a tendinopathy of the 5th metatarsal. Her condition could have been self-limiting. Due to the athletic nature of the of this female athlete and the pressure on her to participate, care and explanation was necessary for quick and favorable conclusion. The findings in this case will not necessarily apply to other young injured athletes.
Arriving at a reasonable explanation to the parents and the need for care both office and home is essential for recovery. One may conclude it was or was not Iselin’s disease. It was the authors opinion because of the focal pain, negative imaging study and no foot pain with motion, Iselin’s was the most likely cause of this young athletes pain and limitations.
Consent was provided by the patient’s parents.
I would like to thank Dr. James Brandt for his guidance and encouragement.
The author has no competing interest.
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