Heel Pain in the Child Athlete
Dr. Jennifer E. Tauber, DPM
Heel pain in kids is becoming much more common as they are becoming increasingly more athletic at younger ages and because more frequently kids are playing sports all four seasons without rest. This pain is often caused by calcaneal apophysitis or "Sever's Disease". I hesitate to call it a "disease" because this can be misleading to many people-it's a very treatable problem with an excellent outcome for the child.
All bones in the human body have growth plates. As our skeleton matures, and we stop growing, the bones fuse. The calcaneas, or heel bone, is the last of the bones in the feet to completely fuse, and in the developing foot this bone is much softer than mature bone. Fusion of the growth plates occurs around the ages of 12-14 for girls and 14-16 for boys. Calcaneal apophysitis occurs when there is irritation of the growth plate which in turn causes heel pain. This type of heel pain has been linked to impact sports that cause repetitive micro-stresses to the open growth plate, such as the impact sports mentioned above. However, I believe that biomechanical issues of the foot are strong contributors as well. For example, most of my patients with this problem also tend to have flat feet (a foot with an insufficient arch), or a pronated ankle (one that bends towards the midline of the body) and tight calf muscles. If a child with flat feet and already tight calf muscles has a growth spurt it tends to make their calf muscle even tighter because sometimes the muscles have a hard time keeping up with the growth of the bones.
Our calf muscles are comprised of three large muscles; the gastrocnemius, which is made up of two large muscle bellies and the soleus (Figure 1). The two gastrocnemius muscles blend to form the Achilles tendon that inserts into the back of the heel bone. In the case of kids, this tendon inserts into the growth plate that is not yet attached to the rest of the heel. If the Achilles tendon is too tight, it causes increased pull on the growth plate which then causes heel pain (Figures 2 and 3).
Fig1
Fig 2
Fig 3 
It used to be that the gold standard for treating calcaneal apophysitis was to take the kids out of their sport for two weeks with rest, ice and elevation. However, in this day in age where kids are very serious about their athletics this is not a solution that's met with enthusiasm. The good news is that they don't have to take time out from their sports. Because the problem is usually related to tight calf muscle, teaching the child to do some simple lower leg stretches can be very helpful to increase their flexibility. These stretches should be done three times a day and before and after exercise. There are a series of stretches that I teach to all my patients who suffer from this issue. One effective stretch starts by facing a wall, about 2-3 feet away. Place both hands on the wall at shoulder height, keeping your legs straight and feet flat on the ground, gradually lean forward until you feel a stretch in the calf muscles (Figure 4). What I always tell my patients is that the stretch should be a little uncomfortable but never painful!
Fig 4
I have found the most important method to address the issue of heel pain in children is to address the biomechanics of their foot structure. To help with this, I usually recommend an over the counter orthotic device with a heel lift, which takes pressure off of the heel. I sometimes also will cast them for custom orthotic devices, which can also be made specifically for the type of athletic footwear that they are wearing.
Athletic footwear is very important to address as well. I frequently find that these children are wearing shoes that are too worn out, poor quality, or not the right size. This needs to be addressed as well, and I ask my patients to bring in their shoe-gear so that I can evaluate it. As soccer cleats are a common form of athletic shoe-gear that I see in my office, I want to make a special note here-never allow your child to use soccer cleats with a three-cleated heel. Cleats should always have four cleats at the heel to evenly distribute the impact at the heel.
With increased stretching, icing, over the counter anti-inflammatories, orthotic devices and a little education, most patients are able to resume their normal activities fairly quickly. However, there are cases where the heel pain is very extreme. In those cases, I will strongly advise rest from their sport. This doesn't mean they have to become completely sedentary. However, they can exchange one activity for another. An alternative, low impact activity such as swimming may be substituted and make resting more acceptable for the child.
If the heel pain is so extreme as to make the child limp and consistently complain of pain, or if there is redness and obvious swelling associated x-rays, I will recommend that x-rays be taken in our office. These x-rays are not taken to diagnose calcaneal apophysitis, but to rule out a fracture, or possibly a bone tumor or infection. In extreme cases of calcaneal apohysitis where the previous mentioned treatments are not effective, I have placed patients in a cast from the knee to the toes in order to keep the achilles tendon in a stretched position. The cast remains on for 3-4 weeks, and once removed normal activities can be resumed-albeit slowly.
The good news is that this is one pediatric condition that a child will outgrow. Once the growth plate has ossified (or fused to the rest of the heel bone), the pain will subside. However, until then the problem can usually be conservatively treated. When it comes to kids, it's always best to be conservative. Whenever a child complains of pain or limps and the reason isn't readily clear, it's always a good idea to have it check out-that's what we're here for!
Next months' article will address training and nutrtition in the child athlete.
