As an allied health practitioner, the chances are pretty high that you’ve come across a child with heel pain regardless of which professional banner you fall under. The most common cause of heel pain in children between the ages of 8 and 14 is Calcaneal Apophysitis, more commonly known as Sever’s Disease.
Despite the name, it is most definitely NOT a “disease”, and I no longer use this terminology during the consultation with the child or their parents. The nocebic nature of the word “disease” can instil unnecessary fear or concern, which may affect the overall reception of the education you give, and the effectiveness of your management plan.
What is it?
Calcaneal Apophysitis is more appropriately described as an overuse injury. It occurs during the years of skeletal development when the calcaneus hasn’t yet fully formed, and a growth plate exists between the metaphysis (main bone) and the apophysis (a separate, proximal/posterior bone section).
Imaging is not required to diagnosis the injury, and only recommended if you want to rule out any differential diagnosis that you may suspect based on your history taking. A positive “squeeze test” is the primary method of clinical diagnosis, and is highly sensitive.
Until the age where the two sections of bone fuse together (which varies) the cells of the growth plate are relatively immature, and rapid proliferation of chondrocytes creates a point of mechanical weakness. This means that this area is more susceptible to injury than in adults, and higher impact activities such as sports involving a lot of running and jumping are frequently associated with the development of pain.
What causes it?
If you ONLY look at the research, the pathomechanics and risk factors in the development of the injury remain a mystery, and the explanations we traditionally give are unfounded.
The recent PhD works of Simon McSweeney for example have found that increased foot mobility (such as seen with excessive foot pronation) is NOT characteristic of calcaneal apophysitis. He also found that the differences in ground reaction forces during running gait under the heels of children with calcaneal apophysitis and those without were NOT significant. Most interesting in my opinion is his third finding that children with calcaneal apophysitis had INCREASED dynamic ankle joint dorsiflexion during running, contrary to popular belief of the opposite being true.
Medial Tibial Stress Syndrome (MTSS) click here…
This means that the two main theories of what causes calcaneal apophysitis, either increased ground reaction forces under the calcaneus or increased tension of the Achilles tendon due to “tight” calf muscles and poor foot biomechanics, are potentially inaccurate, which brings into question some of our favourite management techniques.
When it comes to how we should manage a child with calcaneal apophysitis in our clinics though, it’s important to consider that “Evidence-Based Practice” doesn’t mean “Research-Based Practice”. Being truly evidence-based means:
- Drawing upon the best research available
- Applying the practitioner’s experience and expertise
- Meeting the client’s values and expectations.
When these three aspects come together to form your management plan, only then will you achieve the best results. Children and their parents also want certainty, because they have come to see us for an opinion, advice and a plan moving forward. If we only offer maybe-true or conflicting information based on the research, their confidence in us as a practitioner is not going to be high.
What can we do about it?
To simplify things and create certainty for all involved, I like to educate the child and their parents on the load vs capacity equation. As is the case with most injuries, when the load on the body or that structure repetitively exceeds the capacity of the body to cope with that load, then injuries like calcaneal apophysitis are more likely to occur. The capacity of each individual child’s body to cope with load is going to be different and depend on a whole range of factors (otherwise every child would get heel pain at the same time), so individualised care is the key.
We need to reduce the load going through the heel initially by whatever means we find most appropriate for the child in pain (this is where values/expectations come into play). The most obvious is to just stop playing sport, but this is simply not practical. This is also detrimental to their physical and social health, and calcaneal apophysitis has been found to have an impact on Health Related Quality of Life, as a result of not being able to participate in the sport they love.
Foot orthoses, heel lifts, strapping, footwear recommendations, and myofascial release techniques are all examples of other ways to reduce the pain and load going through the heel at that point in time. Methods such as these can enable the child to continue playing their sport for the rest of the season with much more manageable pain levels. If it works, and provided you have met the expectations and values of the client, it doesn’t matter which combination of these methods you use.
Once load is reduced, it may then be beneficial to improve the capacity of the lower limb to receive increased loads in the form of strengthening exercises. Glute bridges, squats, lunges, step ups, RDL’s and calf raises are all great examples of exercises that may be helpful in improving lower limb strength and resilience to injury in children, provided they are engaging and easy to implement into daily life (again, not always practical!).
What is the prognosis?
Fortunately, calcaneal apophysitis is a self-limiting condition, which means that it will resolve completely once the calcaneus has reached skeletal maturity, and won’t be an ongoing issue. If for whatever reason the child or parents are not able to implement load reduction or capacity building recommendations, then providing this re-assurance to them is most important.
Podiatrist and S+C Coach