Pediatric Heel Pain

Heel Pain in Kids

By far the most common cause of heel pain in children is a disturbance of the growth plate. This is often referred to as Sever’s Disease and/or Calcaneal Apophysitis. The same can occur in the knee and commonly known as Osgood-Schlatters Disease. In these instances the child’s growth plate is inflamed and irritated.

Anatomy of Heel Pain in Kids

The growth plate involved in heel pain found in children is located at the posterior heel bone (calcaneus). This is also the region where the Achilles tendon attaches. The pull of the Achilles tendon is an aggravating factor in children’s heel pain.

Symptoms

Onset of symptoms often correlates to the start of sports and increased activity. Activities likely incorporate overuse and/or repeated minor trauma. Also, a tight Achilles tendon can increase the pull of the Achilles tendon and predispose a child to heel pain. Symptoms arise most commonly between the ages 10-14. Typically, by the age of 16 the growth plate is closed and immune to inflammation. Symptoms can last for as long as the growth plate is open, however flare ups are typically managed successfully within 3-8 weeks.

Treatment

The goal of treatment is to minimize inflammation and therefore reduce pain. Activity modifications are a last resort. First line of defense is NSAIDS, Ice, Stretching and Physical Therapy. In addition, protected weigh-tbearing can be achieved using a cam walker. Relieving tension along the achilles tendon can be achieved using gel heel lifts which also provide cushion. If symptoms persist activities can be reduced and/or stopped. In rare and severe cases a child may need to be casted and use crutches.

Management by a podiatric physician is often wise to be sure diagnosis is correct.

Achilles Tendonitis

Tendons by definition connect a muscle to a bone. The Achilles tendon connects the calf (gastrocnemius) muscle to the heel bone.

Achilles tendonitis is an inflammation of the Achilles tendon. This inflammation is typically episodic initially but can develop into a chronic problem. Over time the chronic condition usually leads to degeneration or micro trauma of the tendon. Often the insertion of the Achilles tendon is the focus and micro tears and thereafter pain, stiffness and swelling. When the disorder progresses to degeneration and micro tears, the tendon may also become enlarged as a consequence of chronic inflammatory changes and damaged tissue.

Achilles tendonitis is categorized as “overuse” injuries and are precipitated by a sudden increase of a repetitive activity involving the Achilles tendon. This repetitive activity leads to micro-injury of the tendon fibers and without appropriate rest the body is unable to repair the injured and inflamed tissue. Chronic inflammation and repetitive trauma will reduce the structural integrity of the tendon and likely cause pain at the site.

The phrase “weekend warrior” is commonly associated with Achilles tendon injury. In the setting of poor conditioning and repetitive stress Achilles tendons are susceptible to strain, inflammation, and/or rupture.

In diagnosing Achilles tendonitis, the patient’s history is most telling along with an exam with reproducible pain at the Achilles insertion, posterior heel, and/or along the tendon. The extent of the condition can be further assessed with x-rays, ultrasound or MRI.

Treatment approaches for Achilles tendonitis is selected on the basis of how long the injury has been present and the degree of damage or degeneration to the tendon.

Initially when there is sudden (acute) inflammation, treatment is focused on immobilization, “deflamming” the area with ice, anti inflammatory medications, and physical therapy, which may include stretching, soft tissue massage, and/or ultrasound therapy. Also heel lifts decrease strain and reduces pain at the Achilles tendon

If non-surgical approaches are ineffective and complete resolution is not attained surgery may be necessary. The foot and ankle surgeon will select the best procedure to repair the tendon.

Juvenile Bunions

"Kiddie" Bunions

When we think of bunions we think of our mothers and mothers. However, bunions can affect, quite severely children and teens alike. For the most part children are without symptoms of pain as they are not subject to the degenerative changes seen in long standing adult deformities. A child’s first complaint is difficulty fitting into shoe gear. For many, cosmesis and feelings of self-consciousness are a concern at initial presentation.

Juvenile bunions are by definition more severe as the onset of the deformity is earlier and the progression faster and left untreated can lead to significant disability. Therefore juvenile bunions are treated aggressively to ensure the lowest rate of reoccurrence. At least 50% of juvenile bunions are associated with a flexible flat foot. Both the flattening appearance of the arch and the protruding big toe are secondary to hypermobility of multiple joints.


Juvenile bunions are more challenging to manage because children and teens are still growing and must be taken into account when directing a treatment plan. Girls growth plates tend to close be age 16 where as boys can take an additional year or so. Closing of the growth plates is what dictates when surgical intervention can be entertained.

Prior to surgical intervention there are a number of effective conservative options, which can be utilized with excellent results. Conservative options include custom orthotics, shoes gear modifications, padding, and anti inflammatory medications. Custom orthotics control excessive motion (hypermobility), which lead to the bunion deformity. Padding and shoe gear modifications are meant to relieve irritation and “bump pain” which can be a constant source of discomfort.

Regardless of age or symptoms children and teens with bunions can remain active and pain free with the help of a podiatric physician.

Pediatric Flat Feet…Things to know…Questions to ask…

First and foremost flatfeet can be normal as children grow. Infants and toddlers are especially flexible and tend to appear with feet rolled in and pointed outward. As children grow and reach school age and feet remain flattened an evaluation from a podiatrist is warranted. Children often complain of foot pain with activity as well as general leg fatigue. When evaluating a flat foot, points of concern include stiff feet, painful feet with walking and/or activity, a tight Achilles tendon, and very severe flat feet. In these cases treatment can include physical therapy, orthotics (custom and/or over the counter), and possibly surgery in severe cases.

Physical therapy is meant to introduce a stretching routine to both the child and parent. Stretching the Achilles tendon can mean the difference between and painful flatfoot and a healthy pain free flatfoot into adult life. It is important to incorporate stretching into everyday routine.

Orthotics provide support for feet and allow for improved function and ultimately reduce pain and prevent surgery. Orthotics are not corrective. Orthotics simply support, decrease and/or prevent symptoms and improve quality of life. Custom orthotics can be costly especially in growing children. In many cases over the counter support is sufficient, however in severe cases custom orthotics are the best option.

As far as surgery goes it left for a last resort. When painful flat feet interfere with walking, running, and athletic activities and conservative measures have been exhausted surgical intervention is considered. Not only eliminating current symptoms and returning a child to pain free activity, surgical intervention also prevents the onset of symptoms and potential disability in adult life.
When in doubt seek a professional opinion. My goal is to keep your child active and healthy. My motto is “Keep Kids, Kids”. Treatment plans are comprehensive but also realistic for active children and busy parents.