A 12 year old boy presents to the clinic with pain at the back of his heels, which has been present over 4 months. He is a very active boy who runs and plays soccer 8 hours a week. He reports that the pain is much worse after prolonged activity. He understands his symptoms are growing pains, however is very frustrated that he is unable to participate in sports due to the pain.
He has tried voltaren gel and finds that it makes a small difference temporarily. He has also changed his walking patterns to protect the heels.
On visual examination there is moderate swelling and redness at the back of both heels. On physical examination the painful area is squeezed, which is very uncomfortable for the child and elicits his symptoms.
He has Sever’s (also known as calcaneal apophysitis), which is inflammation of the heel bone growth plate, caused by excessive forces. It is very common in physically active growing children aged between 7 to 14 years of age. It is explained to him and his mother that the pain is something he will grow out of past the age of 14, when the plate fuses into bone. However, pain and discomfort can be reduced so he is more comfortable during this phase, and can resume his sporting activities with no or minimal pain.
His running style is assessed, and a thorough biomechanical assessment is conducted. It is noted that he has an early heel lift – indicating he has tight calf muscles. The range of his calf muscles is checked and it is confirmed, they are tight.
The tightness of the calf muscles puts a lot of stress through the Achilles tendon which connects to the back of the heel bone – causing the tendon to pull on the growth plate of the bone, hence causing inflammation.
His footwear is also not appropriate for his foot function, or his condition. The stress on the heels remains while using his running and everyday shoes.
A short term treatment plan consisting of resting, icing and elevating the heels with a pair of heel raises placed inside the shoes was put in place. The child was also asked to reduce training load over the next few weeks to allow recovery of the inflamed growth plate.
In the long term, the correct technique of performing calf stretches was demonstrated. His running style was also modified, as his previous running style was putting a lot of strain through the calf muscles and achilles tendon. Footwear changes were also made.
He did not need orthotics as he had no biomechanical issues that needed to be addressed.
At his 4 week follow up, marked improvement was noticed as he was very compliant with the treatment plan. That weekend he ran and reported no pain during or after the run.
He was asked to maintain good calf range and return to the clinic if pain returned.
Written by Karl Lockett