Heel pain in the arena of Foot and Ankle specialists is like the common cold for a Primary Care physician. The vast majority of the time it is diagnosed as Plantar Fasciitis and is on the bottom of the heel, usually at the instep. It can however be a variety of other diagnoses including insertional achilles tendonitis, retrocalcaneal bursitis, or neuritis just to name a few. In Adolescence, heel pain is also quite common but is rarely any of the above mentioned.
The most common diagnosis in athletically active youth, roughly between the ages of 6-13 is Calcaneal Apophysitis or Sever's disease. Sever's Disease, here after referred to as SD was initially described by Sever in 1912. Historically it was most often seen in adolescent boys who were involved in a variety of sporting activities. Times have changed and girls are participating just as actively in athletics and are subject to the same pathology. The usual presentation is pain in the back/bottom of the heel that is aggravated by activity and resolves to some extent with rest.
Sever's Disease is not a disease in the sense of an infection or other chronic pathology but is an injury/irritation of a growth plate. The Calcaneal growth plate or growth plate in the heel bone has attachments from the achilles tendon and the plantar fascia. Pull from either or both of these structures can cause enough motion within the apophysis or growth plate space to create irritation and inflammation which can be quite painful and limiting. This can start when the growth plate is still wide open but is more often seen as the growth plate starts to close further limiting its ability to move with the traction of soft tissue attachments. It was believed by Sever that fractures within the growth plate were the source of the discomfort. When looking at a growth plate that has started to close it can appear to be fragmented into 2 or 3 pieces. It has since been proven that this is the normal appearance of a closing growth plate.
The disease itself is self limiting and will resolve regardless of treatment once the growth plate has fully closed. Depending on the age of the youth at onset this could be a problem for many years. Treatment has always been aimed at managing the pain as well as the inflammation. This is done with the rest, ice, non steroidal anti-inflammatories like ibuprofen, stretching, taping, heel cups, heel lifts and orthotics. In severe cases, cast or walking boot immobilization is used. Each of these have differing levels of efficacy but in my experience orthotics are the golden treatment or the silver bullet. I am not talking about your run of the mill over the counter Dr. Scholls shoe insert. These definitely have their place in the world but not here. Custom molded orthotics made from a mold taken of the youths foot will provide the necessary control and support to stop the pain cycle. We can safely report over 85% of patients who are able to get back to sports and other activities as long as they wear the orthotics in supportive shoes as directed.
As previously mentioned, both the achilles tendon and the plantar fascia have attachments to the growth plate. Increased activity with sports, coupled with slight irregularities in normal gait like pronation cause micro atypical motion/trauma within the growth plate. This motion/trauma is the source of the pain. When the youth is casted in a neutral position the resulting orthotic allows them to function in that position, thus controlling the motion and stopping the pain. A proper custom orthotic will completely resolve the SD in a matter of weeks and the youth will be able to regain full activity without limitations. I treat many painful pathologies and deformities in the feet with custom orthotics. Very few respond as well as does SD.
Another pearl to add when treating SD is a thorough assessment of their cleats. If you look on the bottom there is often a posterior spike which is positioned anatomically directly below the growth plate. Getting a new cleat without a spike in this area or simply grinding down the spike on the old cleat will also significantly reduce impaction trauma and irritation to the area.
If you or your child has SD and you have been told to deal with it and manage the symptoms when they come and eventually it will resolve on its own don't settle for it. A simple, custom orthotic can and will be a game changer. We cast patients for these devices in our offices and can have them ready for fitting in 2-3 days.
Any questions, thoughts or comments are always welcome.
Dr. Darren Groberg, DPM
Dan Preece, DPM & Darren Groberg, DPM