Wednesday, October 17, 2018

Kids Shouldn't Be Sidelined by Heel Pain

A common complaint among my young, athletic patients is heel pain. Typically, this complaint will come from a boy between the ages of 8 and 12- but girls are affected by this as well. More often than not, these kids have had a recent growth spurt. 

Heel pain among kids is usually encountered in impact sports, such as basketball, soccer and running .Kids usually, but not always, have pain in both heels while they are exercising and for a short time afterwards. In most instances, the pain goes away when they are not playing the sport and rest. 

A lot of times, parents will notice their child limping off of the playing field in absence of any injury will playing.  Usually there are no signs of swelling, bruising or redness, which can be confusing to the parent of a child who is acting as if injured.

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.  Calcaneal apophysitis or "Sever's Disease" is the most common cause of heel pain in kids. 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 particularly to impact sports because of the repetitive micro-stresses to the open growth plate.. However, I believe that biomechanical aspect to this issue 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 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). 


             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. That's where stretching, good shoes and an orthotic or insert will get the child back to their sport quicker.

Because the problem is usually related to tight calf muscles, 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

Again, these children tend to have flat feet. Therefore, I usually recommend an over the counter orthotic device with a heel lift, which takes pressure off of the heel. Or, in more server, cases I will cast them for custom orthotic devices.  The advantage to custom orthotics is that they can 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. 
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 checked out.

Dr. Jennifer Tauber is a podiatrist at New Canaan Podiatry, LLC.  107 Cherry Street New Canaan, CT  06840.


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Kids Shouldn't Be Sidelined by Heel Pain

A common complaint among my young, athletic patients is heel pain.  Typically, this complaint will come from a boy between the ages of...