Dr. Vincent Giacalone
Podiatric Medicine & Surgery
466 Hook Rd., Suite 24D, Emerson, NJ 07630
Children’s Heel Pain
What is heel pain in children?
Heel pain in children, like the heel pain that occurs in adults, is very common. Of those children who do get heel pain, by far the most common cause is a disturbance to the growing area (the growth plate or apophysis) at the back/bottom of the heel bone (calcaneus) where the strong Achilles tendon attaches. This is known as Server’s disease or calcaneal apophysitis (inflammation of the growth plate). It is most common between the ages of 10 to 14, seen in boy and girls and can occur in both heels.
The anatomy of heel pain in children
When a baby is born, several of the bones in the foot are still cartilage then begin to develop into bone. When the heel (calcaneus) starts to develop into bone from cartilage (a process called “ossification”), there is generally one large area of development that starts in the center of the cartilage heel, this area is called the primary ossification center. This area, spreading out from the center, replaces the cartilage and eventually the entire heel becomes bone. A second area of bone development occurs at the back of the heel bone, called the secondary ossification center or apophysis (see the x-ray below). These two areas of developing bone will have an area of cartilage between them, this is how the bone grows in size. Around age 16, when growth is nearly complete, these two bony areas fuse together. Server’s disease or calcaneal apophysitis is generally considered caused by damage or a disturbance in this area of growth, usually brought on by increasing physical activity.
The secondary ossification center (Growth Plate or Apophysis). The two growth areas of the heel bone can be seen on this x-ray. The smaller area to the back of the heel is normal. Notice the small cartilage joint between the two areas of bone, that is the growth plate.
What are the symptoms of heel pain in children?
Pain is usually felt at the back, bottom and side of the heel bone. Sometimes there may be pain at the bottom of the heel as well. The pain is usually relieved when the child is not active but becomes increasingly painful with sports or activity. Squeezing the sides of the heel bone is often painful, while running and jumping make the symptoms worse. One or both heels can be affected. In more severe cases, the child may be limping.
What causes heel pain in children ?
The cause of Server’s disease is not entirely clear. It is most likely due to overuse or repeated minor trauma that happens during sporting activities. The cartilage joint between the two parts of the bone cannot withstand the increased forces of the activity. Some children seem to be more prone for an unknown reason, combine this with sport, especially if played on a hard surface and the risk of developing heel pain increases. Children who are over their ideal weight are also at greater risk for developing calcaneal apophysitis. A tight calf muscle and or Achilles tendon is also common in those who develop calcaneal apophysitis. If you look at the x-ray above, you can imagine how much pull there is from the calf muscles via the Achilles tendon on the small growth plate at the back and the stress this will place on the cartilage joint between them.
Self management of heel pain
If your child has Server’s disease, the following is suggested. Cut back on sporting activities, don’t stop, just reduce the amount until symptoms improve (if the condition has been present for a while, a complete break from sport may be needed). Providing the child is not allergic and is of the appropriate weight and age, the use of anti-inflammatory medications, such as Motrin of Advil, may be helpful. The medication may be taken prior to sporting activities. Avoid going barefoot. A soft cushioning heel raise is very important, which reduces the pull from the Achilles tendon and calf muscles on the growth plate and increases the shock absorption, so the growth plate is not pulled as severely. Stretch the calf muscles, provided the stretch does not cause pain in the area of the growth plate is extremely important. The use of an ice after activity for 20 minutes is often useful for calcaneal apophysitis. This should be repeated 2 to 3 times a day.
Podiatric management of heel pain in children
Management of Server’s disease by a Podiatrist is often wise. Other than Server’s disease, there are a few very rare problems that may be causing the pain, so a correct diagnosis with a clinical examination and X-rays is extremely important. Advice should be given on all that is mentioned above – appropriate activity levels, the use of ice, always wearing shoes, heel raises and stretching, etc… follow this advice!!!
A flat or pronated foot is common in children with this problem, so the use of foot orthotics long term may be important. If the symptoms persist and do not responding to these measures, in some cases the foot and leg may need to be put in a special boot or cast for 2-6 weeks to give the area an opportunity to heal. After the calcaneal apophysitis resolves, prevention with the use of stretching, good supportive shock absorbing shoe and heel raises are important to prevent a reoccurrence.
What are the long term consequences of Server’s Disease
This condition is self-limiting, it will go away when the two parts of bony growth join together, this is natural. Unfortunately, Server’s disease can be very painful and limit sport activity of the child while waiting for it to resolve, so treatment is often advised to help relieve the pain. In a few cases of Server’s disease, the treatment is not successful and the child will be restricted in their activity levels until the two growth areas join, usually around the age of 16. There are no known long term complications associated with Server’s disease.
Calf Stretching Exercises
Any of the following exercises will accomplish a good calf stretch. Stretch the calf and hold the stretch for 10-15 seconds and then release. This should be done 10-15 times, 3 to 4 times a day. In addition it should be performed prior to and after sports, exercising and physical activity.
Dr. Giacalone has been trained specifically and extensively in the diagnosis and medical and surgical treatment of foot disorders. Dr. Giacalone has been board certified by The American Board of Podiatric Orthopedics and The American Board of Podiatric Surgery since 1993 and 1995 respectively and is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Giacalone recently practiced at the Hospital for Joint Diseases in New York City. Dr. Giacalone performs surgery at Hackensack University Medical Center (HUMC) in Hackensack, HUMC @ Pascack Valley in Westwood and Surgicare Surgical Center in Oradell.