A 9-year-old male came to clinic with intermittent right heel pain for 2 months. He played soccer on a school team, and many other sports with his family and friends at home. His mother said that over time he seemed to be complaining more overall, and the complaint would occur after shorter periods of activity. The pain seemed to subside fairly quickly after the activity. Over the last week, he had stopped playing during a soccer game because of the pain. The past medical history was non-contributory.
The pertinent physical exam showed a healthy male with growth parameters in the 10-50% and normal vital signs. The pain was reproduced with dorsiflexion of the right heel and pressure on the plantar/posterior area of the heel. There was no edema or erythema noted. The rest of the musculoskeletal and neurological examination was negative. The diagnosis of an overuse injury of the Achilles tendon was made. The patient was instructed to do heel-cord stretching and to cut back on his activities. After two weeks of this treatment, he participated in a soccer tournament and had to stop playing because of pain. The family wanted to consult an orthopaedist who diagnosed the patient with Sever’s disease and in addition to the previous recommendation added a heel cup to his shoe. Over the next couple of months, the pain slowly resolved.
Acute and overuse injuries are common reasons that children and adolescents present to the clinic or emergency room. Overuse injuries that cause heel pain includes calcaneal apopysitis, retrocalcaneal bursitis, plantar fasciitis, and Achilles tendonitis. Other causes can include osteomyelitis, osteoid osteoma, and bone coalition (2 or more bones in the midfoot or hindfoot are joined, such as tarsal coalition) or accessory bones (such as os navicularis).
Osteochrondroses are a group of injuries to the physis, epiphysis and apophysis. An apopysis is a secondary ossification center located at the tendinous insertion into a bone. Site irritation is called apophysitis and several proposed causes include genetics, rapid growth, trauma (compression or traction), anatomical differences and diet. Whatever the etiological factors, it causes pain. Examples include Osgood Schlatter disease of the tibial tubercle or Iselin’s disease at the base of the fifth metatarsal.
Calcaneal apopysitis is also known as Sever’s disease. It is often seen in active children during late childhood and early adolescence. Repeated stress of the Achilles tendon into the calcaneus causes microfractures with resultant swelling and pain. Pain is located on the heel inferiorly and posteriorly. Pain is increased with dorsiflexion and exercise, but modification of activity and heel cushioning improves the pain. Good heel cord stretching prior to activity also improves the problem. If conservative treatment does not improve the problem, a period of non-weight bearing with or without immobilization may be required.
Radiographs may or may not be helpful as there is variation among individuals and one study of blindly-read radiographs without any clinical history did not find a correlation with clinical symptoms.
In 1000 consecutive visits to an outpatient general pediatric clinic, 61 were for musculoskeletal complaints with 5 (8.2%) being for heel pain, with 3 for Sever’s disease and 2 for plantar fasciitis. Sever’s disease accounts for ~8% of overuse injuries in children and adolescents.
Questions for Further Discussion
1. What causes forefoot pain?
2. What causes ankle pain?
3. What are indications for orthopedic evaluation for foot pain?
- Disease: Calcaneal Apophysitis | Sever’s Disease | Foot Injuries and Disorders
- Symptom/Presentation: Foot Pain
- Specialty: Orthopaedic Surgery and Sports Medicine
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Foot Injuries and Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Mier RJ, Brower TD, Pediatric Orthopedics A Guide for the Primary Care Physician. Plenum Medical Book Co.. New York NY, 1994;36-37.
de Inocencio J. Musculoskeletal pain in primary pediatric care: analysis of 1000 consecutive general pediatric clinic visits. Pediatrics. 1998 Dec;102(6):E63.
Kose O, Celiktas M, Yigit S, Kisin B. Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever’s disease)? J Pediatr Orthop B. 2010 Sep;19(5):396-8.
Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep. 2010 Sep-Oct;9(5):265-8.
Becerro de Bengoa Vallejo R, Losa Iglesias ME, Rodriguez Sanz D, et al.. Plantar pressures in children with and without Sever’s disease. J Am Podiatr Med Assoc. 2011 Jan-Feb;101(1):17-24.
Scharfbillig RW, Jones S, Scutter S. Sever’s disease: a prospective study of risk factors. J Am Podiatr Med Assoc. 2011 Mar-Apr;101(2):133-45.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital