Heel pain in children is very rare unlike the common heel spurs in adults. By far, the most common cause of heel pain in children is a disturbance to the growing area at the back of the heel bone where the strong Achilles tendon/heel cord is attached. While some children are seen to be more prone to it than others, overuse or overstress of the foot in sports especially on hard surfaces is considered to be the most common cause.
Brief anatomy
An epiphyseal plate/growth plate is an area at the end of a developing bone where cartilage cells change over time into bone cells. As this occurs, the growth plates expand and unite resulting in the growth of the bones. During growth of the heel bone, one large area of development starts in the center of the cartilage of heel which gradually spreads to fill up the cartilage. There is another area of development at the back of the heel bone. These two bony areas fuse together when growth of the bone is nearly complete. Damage or disturbance in this area of growth can cause Sever’s disease.
About Severs Disease
Sever’s disease/calcaneal apophysitis, is a painful bone disorder that develops as a result of inflammation/swelling of the growth plate in the heel. During the growth spurt of early puberty, the heel bone/calcaneus sometimes grows faster than the leg muscles and tendons. This causes the muscles and tendons to become tight. As the heel area is less flexible, during weight bearing activities the tight heel tendons may put too much pressure on the growth plate. The Achilles tendon/heel cord is the strongest tendon that attaches to the growth plate in the heel. Repeated stress on the already tight Achilles tendon can damage the growth plate over a period of time and lead to the swelling, tenderness and pain over the heel that is characteristic of Sever’s disease.
Physically active girls and boys between the ages of 8 years to 10 years and 10 years to 12 years of age respectively are seen to be commonly affected. The child is at maximum risk for the condition during the growth spurt in early puberty. Children who play soccer, practice gymnasts, or do any running or jumping activity are at an increased risk. It is seen in children who are heavier, have a tight calf muscle, or have a pronated foot i.e. foot rolled in at the ankle that may cause an uneven weight bearing on the back part of the heel bone. The back of the heel typically finishes growing by the age of 15 years; hence the condition is not very common among older teenagers. Also, poor-fitting shoes are seen to contribute to the condition by not providing enough support or padding for the feet or by rubbing against the back of the heel.
Symptoms
Heel pain and tenderness in one or both the heels is the most obvious sign of the condition. There may be swelling and redness in the heel with difficulty in walking. A child suffering from the condition is seen to limp and show a tendency to tiptoe. He/she may feel an increase in the pain on running or jumping. Symptoms are seen to be usually worse during or after activity and get better with rest.
Diagnosis
A doctor may be able to diagnose the condition based on the symptoms reported. The doctor may seek to know details on the child’s activity levels and participation in sports. On physical examination, squeezing the back part of the heel from both sides at the same time or standing on tiptoe may cause pain in the child. There may also be a reduction in the range of ankle motion and tightening of the heel tendons. Imaging tests such as X-rays may be ordered to rule out other conditions such as fractures.
Treatment
As the immediate goal of treatment is pain relief, medicines such as acetaminophen or ibuprofen may be prescribed to ease the pain. Cutting down or stopping any activity that causes heel pain is of utmost importance. Application of ice to the injured heel for about 15 – 20 minutes three times a day may help. Ice should be applied by covering it in a wet towel as direct application can cause ice burns. The child should never be allowed to go barefoot. The doctor may recommend use of orthotics, arch supports or heel cups in children who have a high arch, flat legs, or bowed legs. Use of an elastic wrap or compression stocking can help decrease pain and swelling. In very severe cases, it may be recommended that the child wear a cast for a period ranging anywhere from 2 to 12 weeks in order to immobilize the foot and ensure faster healing.
Any long term problems are rare linked with Sever’s disease. If there is no improvement in the heel pain with treatment, worsening of pain, changes in skin color, swelling of the affected part consultation with the doctor may become necessary. With proper care the condition is seen to usually go away within 2 weeks to 2 months and does not cause any problems later in life. Earlier the disease is addressed, the quicker the recovery is. A child with Sever’s disease can return to physical activity and start playing sports once the heel pain is gone.
Role of stretching exercises
Exercises that stretch the hamstring and calf muscles and the tendons on the back of the leg can help. The child needs to stretch both legs even if the pain is in one heel. Each stretch should be held for a period of 20 seconds and repeated at least 2 to 3 times in a day. Exercises to strengthen the muscles on the front of the shin can also help. It is also called as foot curling and needs to be done at least 3 times a day. For this the child has to sit on the floor keeping the hurt leg straight. One end of a bungee cord or piece of rubber tubing needs to be hooked around a table leg and the other end needs to be hitched around the child’s toes. The child has to scoot back just far enough to stretch the cord and then slowly bend the foot toward his/her body. He/she has to slowly point the foot in the opposite direction i.e. towards the table when he/she cannot bend the foot any closer.
Preventive measures
Long term measures are needed to protect the heel during a child’s growing years in order to prevent recurrence of the condition. Maintaining good flexibility by encouraging the child to do stretching exercises during the growth spurt can reduce the child’s risk for injuries. Wearing of good quality, well fitting shoes with shock absorbent padded soles is important to help reduce pressure on the heel. Avoiding excessive running on hard surfaces can help. Recurrence of the condition can be prevented by application of ice on the heel and stretching after physical activity. Heel pads, heel lifts, or heel arch supports can help if the child has a pronated foot, a flat or high arch. Weight loss may be necessary in an overweight or obese child to decrease pressure on the heel.
Outlook
Sever’s disease is a condition that affects growing adolescents, usually between the ages of 9 to 14 years old as it occurs just before the closing of the heel bone growth plate. This condition is self limiting as it goes away when the two parts of bony growth join together usually around the age of 16 years. Unfortunately, Sever’s disease can be very painful and can limit sport activity of the child while waiting for it to go away. Hence treatment is often advised to help relieve the pain. Also after the calcaneal apophysitis resolves, prevention with the use of stretching exercises, good supportive shock absorbing shoe and heel raises are important to prevent it happening again. But the most important and positive aspect of the condition is that it is not associated with any long term complications.
