Month: June 2021

Iselin’s Syndrome


  • Iselin disease is a painful inflammatory condition of the apophysis (growth plate) of the 5th metatarsal (little toe bone), where the peroneus brevis inserts.
  • The growth plate is the area that bone grows from in children.
  • The growth plate is made up of cartilage, which is softer and more vulnerable to injury than mature bone. This growth plate also serves as an attachment site for the peroneus brevis muscle and the plantar fascia.
  • Iselin disease is most often seen in physically active boys and girls between the ages of 8 and 13 years of age but it can occur in younger children who are particularly active.
  • This condition is most common in those that participate in soccer, basketball gymnastics and dance.


  • Iselin disease is an overuse injury caused by repetitive pressure and/or tension on the growth center at the base of the fifth metatarsal.
  • Running and jumping generate a large amount of pressure on the forefoot.
  • Change of direction activity and heavy plyometric exercises are risk factors for Iselin disease because they increase the tension at the insertion of peroneus brevis.

Signs and Symptoms

  • Pain is most commonly found along the outer edge of the foot and is worsened with activity and improved with rest.
  • A limp on the affected side is likely to be present.
  • The child may walk on the inside of the affected foot to decrease tension through the insertion of peroneus brevis into the base of the 5th
  • The skin overlying the base of the 5th toe bone may be swollen, red, and/or painful to touch.


  • The diagnosis of Iselin Disease is made primarily by clinical presentation and physical exam. Pain with palpation at the widest part of the lateral foot is the most common sign.
  • Xray or ultrasound are generally not required to diagnose the disease, but they may prove useful in assessing for displacement of the growth center and excluding other causes of foot pain.


  • A short period of rest from aggravating activities to reduce inflammation and allow release of pressure on the tendon insertion is recommended.
  • Applying ice for 10 to 15 minutes every 2 to 3 hours is helpful to reduce pain and swelling. Ice is only really required to minimise pain as it won’t improve healing.
  • Non-steroidal anti-inflammatory medications such as ibuprofen or naproxen may also be beneficial in relieving inflammation and pain in the early stages.
  • Tension on the growth plate can be relieved by gentle massage of the calf and lateral shin muscles.
  • Properly fitting running shoes and/or arch support inserts are very helpful in decreasing pain on return to explosive activity.
  • If the individual fails a trial of massage, gentle stretching, rest, ice, and pain medications, the affected limb may be immobilised in a cam/walking boot for a short period until pain has decreased.

Return to Activity and Sports

  • Despite having a goal to return the patient to his or her sporting activities as quickly as possible, playing with pain will not only inhibit healing of the affected growth plate but may further injury the affected foot.
  • Activity however is best continued but guided by pain rather than completely resting and then reloading too rapidly.
  • The longer the individual has been plagued by the injury, the more time is required for symptoms to resolve.
  • Symptom minimisation and healing, if completely detached at the growth plate, typically takes anywhere between 3-12 weeks and is likely nearing completion when the patient can meet the following:
    • Completing full range of motion without ankle pain
    • No pain at rest
    • Ability to walk, jog, and sprint without pain
    • Ability to jump and hop on the affected side without pain
  • If pain recurs upon returning to sporting activities don’t despair, the individual should rest, ice, massage and gentle stretch until the pain has resolved before trying to return to play again.


  • A dynamic and gradually increasing warm-up before starting any activity. A warm up regime such as the Fifa11+ is a great, researched warm up regime that can minimise risk of injury to the entire body.
  • Wear shoes that fit well and are appropriate for the activity. Replace worn-out shoes as regularly as practicable.
  • Stretch or massage tight muscle groups. A dynamic warm up will go a long way to loosening muscles appropriately.
  • Do not play through pain. Pain is a sign of injury, stress, or overuse. Decreased load or rest is required to allow time for the injured area to heal. If pain does not resolve after a couple days of rest, consult your physiotherapist. The sooner an injury is identified, the sooner proper treatment can begin. The result is less time not being able to play and therefore a faster return to life and sport.


Nutrition and performance

Running food

Adequate fuelling is essential to ensure optimum training and performance for any athlete, or person in general. This can also be said for ensuring a timely recovery from injury or illness. Post-injury nutrition is an important part of the healing process and will complete a good rehabilitation program.

After an injury, our body has an increased nutrient requirement to help the healing process, however given the reduction in activity/training load and therefore energy requirements, most people will reduce their dietary intake and may even lower the quality of the food they consume. One goal during this important recovery period is to prevent, or at least reduce the likelihood of, the loss of lean body mass. Intake of adequate protein that is spread evenly across the day can help with this. This can be from foods such as beef, chicken, egg, legumes or beans.

During rehabilitation it is important to take in required amounts of vitamins and minerals which play a role in boosting our immune system, assisting in collagen formation (important for healing of muscles, tendons and ligaments) and contributing to bony healing. An easy way to do this is to include fresh fruits and vegetables regularly as part of your diet.

Carbohydrates and fats are other important nutrients to consider during recovery. Wholegrain carbohydrates such as oats, brown rice or wholegrain pasta will be higher in fibre which helps with our hunger levels. Omega-3 fats play an important role in mediating the inflammatory process and can be found in foods such as salmon, chia seeds and walnuts.

It is also important to monitor consumption of sugars, fried fatty foods and alcohol during this time as these foods can affect the inflammatory process and reduce our body’s ability to synthesise protein and adequately repair tissue.

For specific information regarding dietary intake and performance talk to your physiotherapist, exercise physiologist or contact your local sports dietician.



Tendons and tendinopathy

Tendons and Tendinopathy.

There is a lot we do not know about tendinopathy, but there are some evidence-based truths that are not common knowledge and should be for best treatment of tendon pain.

Summarised below are some of the most important findings:

  1. Tendinopathy does not improve with rest – the pain may settle but returning to activity is often painful again because rest does nothing to increase the tolerance of the tendon to load.
  2. Although there are some inflammatory biochemical and cells involved in tendinopathy, it is not considered to be a classic inflammatory response. Anti inflammatories may help for very high pain levels but it is unclear what effect they have on the actual cells and pathology.
  3. Tendinopathy can be caused by many different risk factors. The main factor is a sudden change in certain activities – these activities include 1) those that require the tendon to store energy (i.e. walking, running, jumping), and 2) loads that compress the tendon. Some people are predisposed because of biomechanics (e.g. poor muscle capacity or endurance) or systemic factors (e.g. age, menopause, elevated cholesterol, increased susceptibility to pain, etc). Predisposed people may develop tendon pain with even subtle changes in their activity.
  4. Exercise is the most evidence based treatment for tendinopathy – tendons need to be loaded progressively so that they can develop greater tolerance to the loads that an individual needs to endure in their day-to-day life. In a vast majority of cases (but not all) tendinopathy will not improve without this vital load stimulus.
  5. Modifying load is important in settling tendon pain. This often involves reducing (at least in the short-term) abusive tendon load that involves energy storage and compression.
  6. Pathology on imaging is not equal to pain – pathology is common in people without pain. ‘Severe pathology’ or even ‘tears’ this do not necessarily mean a poorer outcome. Further, we know that even with the best intentioned treatment (exercise, injections, etc) the pathology is not likely to reverse in most cases. Therefore, most treatments are targeted towards improving pain and function, rather than tissue healing, although this still is a consideration.
  7. Tendinopathy rarely improves long term with only passive treatments such as massage, therapeutic ultrasound, injections, shock-wave therapy etc. Exercise is often the vital ingredient and passive treatments are adjuncts. Multiple injections in particular should be avoided, as this is often associated with a poorer outcome.
  8. Exercise needs to be individualised. This is based on the individual’s pain and function presentation. There should be progressive increase in load to enable restoration of goal function whilst respecting pain.
  9. Tendinopathy responds very slowly to exercise. We must encourage patience, ensure that exercise is correct and progressed appropriately, and try and resist the common temptation to accept ‘short cuts’. There are often no short cuts.

Please note that these are general principles and there are instances when injections and surgery are very appropriate in the management of tendinopathy.

Abate M, Gravare-Silbernagel K, Siljeholm C, et al.: Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Research and Therapy. 2009, 11:235.
Cook J, Purdam C: Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine. 2012, 46:163-168.
Littlewood C, Malliaras P, Bateman M, et al.: The central nervous system–An additional consideration in ‘rotator cuff tendinopathy’and a potential basis for understanding response to loaded therapeutic exercise. Manual therapy. 2013.
Malliaras P, Barton CJ, Reeves ND, Langberg H: Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine. 2013:1-20.