Adolescent Heel Pain

In this short article I discuss a heel pain condition that affects adolescents – calcananeal apophysitis also known as Sever's disease. How to manage the problem, with some tips on psychology for the younger generation.

Let's look at three whats.

• What is it?

• What are the implications?

• What is the best management?

Heel pain also called Sever's Disease (apophysitis)

The first important fact is that this is not a disease. It is short lived, treatable and for any parent, learning how to support your child or adolescent is the most important learning part of the article.

Our son developed heel pain at 13 years. That is pretty much the time when we see the condition. He was not particularly sporty, but active. Boys have traditionally experienced the problem more than girls, but one should never assume this does not happen in girls, where bone growth matures earlier.

(1) What is it?

Calcaneal apophysitis is the correct name for the pain localised to the heel. It is not a spur or fasciitis, so put that out of your mind and be reassured. The differential diagnosis might include tendonitis, an overuse syndrome. In many ways treatment of calcaneal apophysitis and tendonitis can be treated similarly.

The immature foot seen on X-ray, has gaps, represented by cartilage. This fills in with bone. Secondary bone sites like the heel, come later between ages 6-8 years. The bone then joins from 13 onwards and completed by 16-18 years.

The big tendon in the leg (tendo-achilles or T.A) is in fact made of two muscle tendons which appear consistently (soleus + gastrocnemius). As the most powerful tendon in the leg and ankle, the TA has a huge influence on the foot during motion.

The tendon lifts the heel during walking and running, as well as absorb impact when the heel contacts the ground. Part of the function also controls forward motion, often known as deceleration. Put in simple terms, as the knee bends, the second part of the TA (soleus) slows forward movement. The action associated with deceleration allows smooth movement and stabilises the leg upon the foot.

The tendon has a direct effect on the junction between the primary (main) heel bone and it's secondary centre. The illustration is useful for location, but not the two centres of bone have joined in the image, but in the immature (adolescent) foot, the junction is under stress from the direction of pull.

The Secondary Centre

The secondary heel centre emerges from 6-8 years, but is too small to have much of an effect. The TA is still stable during these years within part of the existing bone and cartilage. Cartilage comes in many forms, and in the skeleton, acts as joint surface covering as well as forming a matrix upon which bone cells mature to form the hardy structure.

A critical point arises when the primary centre and secondary mature suffiently, and yet have not fused together to form the mature outline seen in the figure above. During this narrow period, around the time when children are maturing toward adulthood, excessive exercise can set of inflammation.

https://www.ncbi.nlm.nih.gov/books/NBK441928/#:~:text=Individuals%20should%20apply%20ice%20to,Braces: Smith JM & Varacello MA 2024. Traditional Sever's or agpophysitis showing gap between main bone and secondary centre in adolescence.

X-rays show little except the open gap. More often one side is affected more than the other. The adolescent will limp and find all sporting activities uncomfortable.

Differentiating the problem

If swelling appears it is important to rule out a deep bursitis, which forms as a sac. Infection is rare, and fortunately unlikely, but a second opinion is warranted if there is redness, swelling, heat and localised pain to the touch.

You can read more from the author in his Foot Health Myths, Facts & Fables.

(2) What are the Implications?

Many children do not have any concerns, and this is mostly due to the condition of the TA and tightness. Bone length and repaid growth targets the hamstrings and achilles to you can spot some children walking with a bouncy stride. This corrects as the tendon will adjust by the time long bone (leg & thigh) cease growing, which can be up to 19 in boys and slightly earlier in girls.

Complaints of pain are the obvious signs, the location being around the back of the heel, although, the lower part of the heel may be tender. Those with a dedicated passion for sports will push through. Ideally time is needed to settle the condition and a balance has to be struck between rest, cessation of sport and continuance with some guidance.

To avoid a stand up argument with those who play more than just occasional games, one needs to apply some psychology.

(3) What is the best management

The most important thing that any parent can do is to ensure there is no visible reason for heel pain—a blister, verruca, or small hair from an animal. Get the magnifying glass and have a good look. Is the heel hot and swollen, painful to touch, and does simple pain medicine make no difference? If pain cannot be relieved by medication, try some simple tips. Thereafter DO seek professional help, especially if the foot has been rested and you have done all that you can.

Apophysitis in adolescents is actually self-limiting, and all we are doing is waiting for the two sites making up the heel bone to mature i.e join together. The aim is to remove the tension-pull effect on the smaller part of the heel. The second approach is to assist TA stretch, but first you have to decided what stage your adolescent's condition is in.

Pain & Tenderness

Pain is subjective. What one person experiences is different from another. Age, race, gender, can all play a part in how we feel.

A younger person is resilient. If they have pain, believe them—it is real.

'We need a plan; I think we need to agree a strategy?'

Psychology

Most modern parents work with their children, only dictating when necessary. First, if they want to continue participating in sport, explain the problem. Knowing what it is, you can explain, the pain will go but it is important to not irritate the two bone centres while they are trying to bond.

What happens if I continue?

You will continue to be uncomfortable and your performance won't be as good. You might be letting your team down, especially if it's an important game.

The other concern you might discuss comes from changing the bone's angle and setting up a bony exostosis, or lump, called a Haglund's deformity.

We need a plan; I think we need to agree a strategy?

Let's take some time out. Maybe three weeks. That might not go down well, so let them set a different period you can agree on.

First we need to apply first aid to see if we can get the heel more comfortable.

Reducing Pain

Pain medication is fine for times when there are tears, your child is quiet and not themselves. The usual medications are fine such as paracetamol (Tylenol) or ibuprofen. The gels which contain anti-inflammatory medication can also be helpful.

Remember ICE and cooling the part can help acute pain. Look at this helpful article, going to the cold section. Cold & Heat.

We need to approach the mechanics—taking tension away from the pull on the tendon. This is easy. Use a heel pad to lift the heel 1/4 in or around 6 mm can relieve the pull effect. Once the tension has reduced by using the pad in the shoe whenever active, will help significantly and allow you adolescent child to start to increase activity.

Hold back return for 7-10 days to allow the inflammation to settle. Search for adjustable orthopaedic heel inserts. The ideal design allows you to reduce the heel raise over a period of time. There are a number of different makes on the market.

A gel sleeve will help to reduced direct pressure from the shoe in the early stages and compress the tissues preventing skin irritation.

Now that you have the condition under control. How long will calcaneal apophysitis take to settle? — 6 weeks - 6 months can be taken as guide.

Staggering the return to sports

As far as your adolescent is concerned, they are best reducing the number of times activity takes place within that first six weeks. This means you need to negotiate a staggered return. Once pain is under control, check out how long they are active for. Twenty minutes might be fine to start with, but not ninety minutes.

Once the heel is undercontrol we can now start TA stretching. If you push too soon, whilst the heel is inflamed, then the condition will not settle.

Stretching the achilles

You can apply a similar approach to the condition of fasciitis, also available as an article from ConsultingFootPain. This video is also useful using a stepladder and wall. I've gone for a 3 minute video so this is quick.

Depending on the age of your child, you may need to encourage stretching for at least 6 months, and maybe longer. You can assist with this by wall stretches and using a night brace. I know some people find the designer heel stretchers useful, but this is just extra money you don't need to waste. Night stretching can be achieved passively. The example below is a mid-range Chongni adjustable device priced below £25.00. This is also used for fasciitis. There are a wide range some less expensive and others very much more expensive.

(Plantar Fasciitis) Night Splints: Upgrade Adjustable Breathable Night Splints for Plantar Fasciitis Support with Arch Support, Relief Achilles Tendonitis Foot Drop Heel Pain, Day&Night (Blue)

The first application should not be set at full stretch. This must be adjusted slowly each night / week to obtain a comfortable stretch. Tendon is a soft tissue and will adapt, but there is a balance between comfort, compliance and effectiveness. Day stretches should also be used morning and night, and before activities as well as after, where possible.

David is a former foot (podiatrist) surgeon and university lecturer who has written for Busypencilcase Communications & Publishing under Consultingfootpain since 2015. You can find him on Facebook, LinkedIn and X, and he enjoys hearing from readers about their foot health issues.

Published by Busypencilcase Communications Est. 2015 for ConsultingFootPain