HEEL PAIN IN CHILDREN
Augustine A. Bollo, DPM

There are several heel-related conditions which may cause pain to individuals of all age groups. However, the most common type of heel pain which involves children from ages eight to twelve is Sever's osteochondrosis. Sever's osteochondrosis is a temporary injury to the growth plate of the heel bone. This is not an acute injury, but a chronic repetitive injury to the growth plate in the back of the heel, which occurs during normal child development. The age range of 8 to 12 is a result of the growth spurts that children go through at this time combined with muscular tightness. The bones grow at a more rapid rate than the soft tissues(muscle, tendons) and most children begin to compete at a higher level of competition at this time causing the muscles to become tighter.

Causes

  1. Overuse: This condition most commonly occurs due to overuse, when a child becomes more active during this age group and places increased tension and strain on the growth plate (i.e.. soccer, baseball or extracurricular sport activities.
  2. Tight Achilles Tendon and/or Hamstrings: Tightened muscles in the back of the leg in addition to an increase in the child's activities, will cause an increase in strain on the growth plate in back of the heel.
  3. Flat Feet: Flat feet usually occurs in combination with tight muscles, which not only increases tension in the back of the heel, but torsion on the growth plate due to excessive motion with ambulation. This also predisposes a child to expend more effort to ambulate, which is aggravated with increase in activities.
  4. Acute Injury: Although rare, this may be caused by over flexing the ankle upward with a particular activity, which causes immediate strain to the growth plate.
  5. A combination of any of the above

Symptoms

  1. Localized pain to the back and/or bottom of the heel with ambulation, which is worse with increase in activity level. The pain decreases when the child sits down, but gets worse whey get up to walk again after rest.
  2. Stiffness or tightness in the back of the leg.
  3. Fatigue of the lower extremities.
  4. Occasional discomfort and stiffness when putting the foot on the ground the first thing in the morning
  5. Swelling or discoloration is rarely seen.
  6. The condition may last weeks or may be present on and off for a few years while the child is growing

Signs

  1. Pain with pressure to the back and/or sides of the heel bone.
  2. Occasional pain with palpation along the Achilles tendon.
  3. Usually, tightness of the calf muscle with limited flexion at the ankle.
  4. Many cases are associated with a hyperpronated(loss of arch height)
  5. Pain upon ambulation, especially pushing off of the toes.
  6. No gross swelling and no discoloration.

X-RAYS: X-rays may be negative, however, there is usually presentation of increase in density (whitening) of the back of the heel bone. The growth plate is usually normal in appearance or in some cases with slight irregularity. It is quite often for the growth plate of the heel to be in 2 or 3 pieces(bipartite or tripartite)- many times this fragmentation of the growth plate is misdiagnosed as a fracture.

TREATMENT: Treatment is dependent on the level of pain and difficulty that the child has with ambulation and daily activities, as well as associated predisposing condition. (i.e.. flat foot, tight calf muscles, etc.)

  1. Rest: Initial treatment always includes decrease of the child's activity that is causing pain, or at least modifying the child's activity (i.e.. temporarily have a pinch runner when playing baseball).
  2. Shoe modification: Avoid excessive barefoot walking and wearing flat shoes. Wear supportive cross training-type shoes.
  3. Heel lifts: May purchase a heel lift for temporary relief, to take pressure off of the Achilles tendon, until professional treatment can be sought.
  4. Physical Therapy: Beneficial for decrease in internal edema(swelling) and pain, but more importantly, to increase flexibility and strength to the affected areas.
  5. Orthotics: Custom made arch supports are necessary in children with a hyper mobile or flat foot to correct structural deforming forces along the growth plate and the Achilles tendon.
  6. Medication: Anti-inflammatory medications may help decrease symptoms, while the child needs to be active or until professional treatment can be sought.
  7. Cast Immobilization: Often times, if the patient is having difficulty to ambulate due to pain or has not responded to other treatment modalities, cast immobilization for two to four weeks is very effective to relieve pain and at the same time, passively stretch the Achilles tendon.

CONCLUSION
Heel pain in children is a very common condition, especially in children who are actively involved in sports and other extracurricular activities. Heel pain in children almost always needs to be treated and can be resolved in all cases with Sever's osteochondrosis.


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