Volume 1, Case 20 Answers

The main point of interest in this case is the heel at the achilles tendon insertion. An AP view of the foot was excluded from this case since it was normal and the heel was not visible due to superimposition of other bones.

The oblique view shows crescent-shaped lucencies over the posterior calcaneus in the area of concern. These lucencies represent the growth plate viewed obliquely. The lateral view shows the physis in a truly lateral view. These radiographs of the foot are normal.

Discussion and Teaching Points:

The most common cause of heel pain in adolescents is calcaneal apophysitis (also known as Sever's disease). Radiographs of the heel are felt to be normal as they were in this patient, although some authors have disagreed with this point.
An apophysis is a growth plate that does not contribute to the length of the bone. The achilles tendon inserts in the calcaneal apophysis. The patellar tendon inserts into the tibial tuberosity apophysis. The growth plate is weak and subject to micro-injury if there is excessive force placed on the growth plate.
Developmental changes of the calcaneal apophysis include the onset of ossification at an average age of 8 years in boys and 6 years in girls. For 2 to 3 years thereafter, the ossification appears irregular and there may be deep narrow clefts segmenting the apophysis.
Similar to Osgood-Schlatter disease (tibial tuberosity apophysitis), Sever's disease (calcaneal apophysitis) is an overuse syndrome frequently seen in adolescents in their growth spurt, who are physically active. The most common sports found to exacerbate the heel pain are soccer, basketball, gymnastics, and baseball. Sports that involve sprinting with cleated shoes result in the most force exerted by the ankle flexors on the calcaneal apophysis. Examination of the heel typically reveals tenderness to compression of the medial and lateral sides of the calcaneal apophysis and decreased dorsiflexion of the ankle without any swelling or erythema. Findings are bilateral in about 60% of patients. Radiographs are generally not necessary.
Heel pain in this disorder is felt to be secondary to repetitive microtrauma where the achilles tendon inserts into the apophysis. Successful treatments have included foam heel pads to elevate the heel and reduce the stretch of the achilles tendon. Physical therapy with gastocnemius-soleus stretching and dorsiflexion strengthening has been useful as well. Discontinuing aggravating activities is probably the simplest treatment. Instructing patients to rest when the pain worsens allows them to continue in their sports without the need for orthopedic restrictions. For persistent pain unresponsive to these therapies, short leg walking casts have been used.

References

Meehan P. Heel Pain. In: Morrissy RT (ed). Lovell and Winters Pediatric Orthopedics, 3rd edition. Philadelphia, J.B. Lippincott Co., 1990, pp. 1001-1002.
Micheli LJ, Ireland ML. Prevention and Management of Calcaneal Apophysitis in Children: An Overuse Syndrome. Journal of Pediatric Orthopedics 1987;7:34-38.
Tolo VT, Wood B. Pediatric Orthopaedics in Primary Care. Baltimore, Williams and Wilkins, 1993, p. 229.

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 Loren Yamamoto, 
      MD, MPH Associate Professor of Pediatrics University of Hawaii John A. Burns 
      School of Medicine loreny@hawaii.edu