1. Osteochondroses of the Foot
TONY PASCOE
B.App.Sc. (Pod) Grad.Dip.(Pod) M.A.Pod.A

2. OSTEOCHONDROSES
Group of bone disorders in the growing skeleton in which the centres of ossification undergo aseptic necrosis, followed by bone resorption, and then repair
Primary pathology is a vascular deficit in the subchondral region of the involved bone

3. Osteochondritis
Osteochondritis juvenilis
Aseptic necrosis
Avascular necrosis
Infarction
Osteonecrosis

4. More Common Less Common
Sever’s Disease (heel)
Kohler’s Disease (navicular)
Iselin’s Disease (5th metatarsal)
Freiberg’s Disease (2nd metatarsal)
Less Common
Diaz or Mouchet’s Disease (talus)
Buschke’s Disease (cuneiforms)
Treves’ or Ilfelds’Disease (sesamoids)
Thiemann’s Disease (phalanges)

5. Sever’s Disease (Osteochondrosis of Calcaneal Apophysis)
First described in 1912 by J.W Sever MD in New York Medical Journal
Described as an “inflammation of the calcaneal apophysis resulting in pain at the posterior heel, mild swelling and difficulty walking”

6. Sever’s Disease PATHOPHYSIOLOGY
Calcaneal apophysis develops as an independent centre of ossification in boys aged 9-10 years and fuses by age 17 (girls slightly younger age)
Apophyseal line appears weakened during rapid growth (puberty) because of increased fragile cartilage
Microfractures believed to occur because of shear stress leading to normal progression of fracture healing

7. Sever’s Disease PATHOPHYSIOLOGY
Radiographic appearance of resorption, fragmentation and increased sclerosis leading to eventual union
BUT…… Xrays showing fragmentation of apophysis are NOT diagnostic, as multiple centres of ossification may exist in normal apophysis

9. Normal apophyseal development in a 7 year old child

10. MRI

11. Sever’s Disease INCIDENCE
No exact figures/data
Higher in boys than girls
Occurs most frequently between ages of 8-15 years
Peak incidence around years

12. Sever’s Disease AETIOLOGY
Decreased resistance to shear stress at bone-growth plate interface
Research indicates traction apophyses have a higher composition of fibrocartilage than epiphyses subjected to more axial load, composed predominantly of hyaline cartilage
Traction from tight Achilles tendon

13. Sever’s Disease DIFFERENTIAL’S
Stress fracture
Tumour
Tarsal Coalition
Insertional Achilles Tendinopathy
Osteomyelitis

14. Sever’s Disease TREATMENT
R.I.C.E
Heel raise
Triceps surae stretching program
Correct Footwear
Foot Orthoses if required
Complete immobilisation rarely required

15. Sever’s Disease WHEN TO REFER TO SURGEON
NEVER ……….
Unless suspect tumour, coalition or infection

16. KOHLER’S DISEASE
AVN of navicular bone occurring spontaneously or as a result of trauma during ossification process
Onset at 4yrs (3-5 yrs female, 4-5 yrs male)
Less than 1/3 are bilateral
More common in boys

17. Kohler’s Disease SIGNS AND SYMPTOMS
Pain at navicular
Increased perfusion
Aversion to footwear
Antalgic gait
Flattening and narrowing of navicular on plain xray

18. Kohler’s Disease
Sclerosis, irregularity and early collapse of the navicular consistant with avascular necrosis (Kohler’s disease)

20. Kohler’s Disease PROPOSED PATHOLOGY
Largely speculative, but 3 main theories:
Mechanical: repetitive, compressive forces
Physiological: ossification irregularities are not uncommon and more often seen in later developing bones
Co-morbidities: malignancies, chemotherapy and radiation can cause ossification delays

21. Kohler’s Disease TREATMENT
Rest: As a self limiting disease, normal function will resume within 24 months (avg 18mths)
Orthoses: reduction in compressive force to encourage renewed vascularisation
Immobilisation (BK Cast or CAM walker for at least 8 weeks)

22. ISELIN’S DISEASE Traction apophysitis of tuberosity of 5th metatarsal
Occurs at attachment of peroneus brevis
More common than generally appreciated

23. ISELIN’S DISEASE

24. ISELIN’S DISEASE

25. TIMELINES Occurs in older active children or young adolescents
Coincides with appearance of the proximal apophysis of tuberosity of 5th metatarsal
Apophysis appears in females at age 9.7 yrs and males 12.1 years, and fuses with shaft of 5th met by age 11 yrs in females and 14 years in males

26. SYMPTOMS (ISELIN’S DISEASE)
Tenderness over a prominent proximal 5th metatarsal
Pain over lateral aspect of foot with weightbearing
More common with lateral movement sports which cause inversion stress on forefoot

27. CLINICAL EXAM FINDINGS
(ISELIN’S DISEASE)
CLINICAL EXAM FINDINGS
Larger 5th met tuberosity
Localised soft tissue swelling and mild erythema
Tender at insertion of peroneus brevis
Pain with resisted eversion, plantarflexion and dorsiflexion

28. DIFFERENTIALS (ISELIN’S DISEASE) Avulsion fracture Jones fracture
Os Vesalianum
Peroneal tendinopathy

29. TREATMENT (ISELIN’S DISEASE) R.I.C.E
Foot orthoses with lateral wedging/posting
Footwear choices
Cross training

30. FREIBERG’S DISEASE
First described by Freiberg in 1914 as an infarction of the 2nd metatarsal head
Can affect the head of any lesser metatarsal, 2nd most common (70%)
Onset yrs of age (F>M)

31. AETIOLOGY Freiberg’s disease No consensus
Classed as an osteochondrosis, but this does not explain the adult onset of the disease??
Most likely multifactorial cause, with initial insult primarily vascular or traumatic (?biomechanical influence)

32. CLINICAL PRESENTATION
Freiberg’s Disease
CLINICAL PRESENTATION
Initially asymptomatic, but later pain on walking
Local tenderness and limp
Limited joint ROM with pain on direct palpation of metatarsal head
Possible periarticular oedema and soft tissue swelling

33. DIFFERENTIALS Stress fracture Morton’s neuroma Synovitis
Freiberg’s Disease
DIFFERENTIALS
Stress fracture
Morton’s neuroma
Synovitis
Plantar plate injury
Gout

34. X-RAY CLASSIFICATION Freiberg’s Disease
Fracture of subchondral epiphysis
Flattening of articular surface with early collapse of central protion of metatarsal
Further flattening and collapse of central protion with medial and lateral projections

35. X-RAY CLASSIFICATION Freiberg’s Disease
Loose bodies form and lateral projections break off
End stage arthrosis

36. Freiberg’s Disease
Early Stage 1

37. Freiberg’s Disease
Stage 2 - 3

38. Freiberg’s Disease
Stage 4

39. Freiberg’s Disease
Stage 5

40. Freiberg’s Disease

41. Freiberg’s Disease

42. Freiberg’s Disease

43. TREATMENT Freiberg’s Disease Accommodative padding to relieve pressure
Metatarsal bar/pad
Orthoses
BK casting
Surgical – excision of fragments, metatarsal head removal, joint implants

44. DIAZ OR MOUCHET’S DISEASE
Very rare
Associated with acute trauma with compression of talar dome
Usually remodels to normal shape

45. BUSCHKE’S DISEASE Very rare Effects each of the cuneiforms
Pain in region of cuneiforms
Affected cuneiform has irregular outline on xray

46. TREVES’ OR ILFELD’S DISEASE
Significant pain on dorsiflexion and palpation of sesamoids
F>M
Fragmentation of sesamoid on xray
Need to distinguish from multipartite sesamoid or fracture

47. THANK YOU