HEEL PAIN IN A YOUNG ATHLETE

1
HEEL PAIN IN A YOUNG ATHLETE

• Christopher Meyering, DO
• Fellow, NCC Primary Care Sports Medicine Program
• CPT, MC, USA

2
History

• CC My heel hurts.
• HPI 9 year old female with bilateral heel pain
  for 2 months. Mentioned to mother after playing
  soccer match. Has gradually worsened through the
  season. Now starting to hurt when at school and
  home.
• PMHx Unremarkable. No prior injury reported

3
Differential Diagnosis?

• Calcaneal Stress Fracture
• Plantar Fasciitis
• Tarsal Tunnel
• Retrocalcaneal bursitis
• Calcaneal apophysitis (Severs Disease)
• Infection
• Bone cyst or neoplasm

4
Physical Exam

• Lower Leg
• Normal calf development
• Tib/Fib non tender
• Slight decrease with dorsi-flexion, all other ROM
  normal
• Foot Exam
• Mild Pes Planus and slight pronation with walk
• No discoloration
• TTP on the calcaneus at the Achilles insertion
• Tenderness with transverse plane compression of
  the calcaneus
• Achilles tendon is not tender

5
Diagnostic Studies?

• Plain Films
• MRI?
• Bone scan?

6
Plain Films
7
Final Diagnosis

• Calcaneal apophysitis (Severs disease)

8
Management

• Relative Rest from aggravating activity
• Supervised (parental?) gastroc/soleus stretching
  and strengthening
• Heel Cups
• Cushioned or lifts of ¼ inch.
• Relieves tension/stress on the insertion site

9
Management

• ICE
• Massage or bag for 20 minutes after activity, can
  continue with icing even though improving
• NSAIDS (controversial) or Tylenol?
• Usually not needed unless child has pain with
  ADLs
• Never use to allow child to play through pain

10
Return to Play

• Slow progressive return to activity
• Usually able to return to previous sport in
  approximately 2 months
• May continue to wear heel padding/cups if
  comfortable to wear inside shoes (especially
  cleats)
• Continue with good stretching technique after
  activity

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Complications/ Concerns

• If still having pain despite adequate treatment
  within 4-8 weeks, repeat x-ray to evaluate for
  stress or avulsion fracture
• May consider MRI or bone scan
• May also consider short leg casting for 3-4 weeks
  if concern about a progression to fracture

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Key Points

• Responds well to relative rest and padding
• X-rays typically normal but helps to rule out
  other potential causes for pain
• Gradual return to previous sport in about 2 months

13
References

• Anderson SJ, Lower extremity injuries in youth
  sports. Pediatr Clin North Am (2002) 49
  pp627-641.
• Canale ST, Osteochondroses and related problems
  of the foot and ankle. DeLee JC. Drez D. Miller
  MD. 2nd edition. Orthopedic sports medicine
  principles and practice 2003 Philadelphia
  Saunders pp 2587-2623.
• Christopher NC, Congeni J, Overuse injuries in
  the pediatric athlete evaluation, initial
  management, and strategies for prevention. Clin
  Pediatr Emerg Med (2002) 3 pp 118-128.
• Harty MP, Imaging of pediatric foot disorders.
  Radiolo Clin North Am (2001) 39 pp733-748.