SplintER Series: Ankle and Foot Pain in a Child

Posted by William Denq, MD CAQ-SM on Sep 04, 2019

A 10-year-old female dancer presents with sub-acute onset pain located in her lateral ankle and foot without any history of significant trauma. She has had similar pain occasionally over the past 6 months. Pain is worse while dancing and now has difficulty putting on her shoe. You obtain a foot x-ray and see the adjacent image (photo credit).

What is the most likely diagnosis, differential diagnosis, and appropriate management plan?

What is your diagnosis?

Traction apophysitis at the base of the 5th metatarsal (MT). Also known as Iselin’s disease.

Do not confuse this with a base of the 5th MT fracture. These are typically horizontally oriented whereas the 5th MT apophysis is almost vertically oriented. Another important differentiator between Iselin disease and 5th MT fractures is time course. Although patients may report acute worsening of symptoms or feel that the symptoms began when they ‘landed wrong,’ a more detailed history may elicit similar previous pain, indicating a more subacute process.

Read more on ALiEM about 5th metatarsal fractures

What is the pathophysiology for this disease?

The same as for Osgood-Schlatter (Iselin’s disease is also known as Osgood-Schlatter of the foot).¹ It is a stress reaction at the insertional apophysis from overpull of the peroneus brevis.²

What is your expected history and physical exam?

In Iselin’s disease, the pain typically begins after activity, however may progress to pain with any movements that cause inversion at the ankle such as with running, dancing, or cutting. Putting on a shoe may become difficult secondary to pain and swelling. Focal tenderness can be elicited and erythema/edema may be seen at the base of the 5th MT. Resisted eversion or passive plantar flexion and inversion may reproduce pain.²

What is your management plan?

Ask the parents to suspend the child’s activities and use ice with acute flares. Recommend a wider shoe if the apophysis is causing her pain with regular walking. Consider a post-op shoe. Offer crutches if the patient has difficulty with ambulation (be sure to rule out fracture). If these management options have already been tried prior to arrival, consider a posterior short leg splint or CAM walking boot.

When would you consult orthopedics in the ED?

Never. Unless it is not Iselin’s disease and instead a fracture that is open or involves neurovascular compromise. Remember 5^th MT fractures are generally horizontally oriented while the apophysis is vertically oriented. Follow up in 1-2 weeks.

For more cases like these, you can subscribe to the Ortho EM Pearls email series hosted by Drs. Will Denq, Tabitha Ford, and Megan French, who have kindly shared some of their content with ALiEM.

References:

Iselin H. Growth problems at the time of bony development of tuberosity metatarsi quinti. Langenbeck’s Archives of Surgery 117.5 1912;117(5):529-535. https://doi.org/10.1007/BF02794784
Lehman RC, John RG, and Torg E. Iselin’s disease. The American journal of sports medicine 1986;14(6):494-496. https://www.ncbi.nlm.nih.gov/pubmed/3799877

Author information

William Denq, MD CAQ-SM

Assistant Professor
Department of Emergency Medicine
University of Arizona

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Tags: Expert Peer Reviewed (Clinical), Orthopedic, SplintER