Pediatric Heel Pain
(Sever's Disease / Calcaneal Apophysitis)

CONDITION

Sever's disease, also known as calcaneal apophysitis, is a condition in which pain occurs where the tendon from the lower leg (the Achilles tendon) attaches to the back of the heel bone (calcaneus) (Figure 1). An area of cartilage sandwiched between immature heel bones (the growth plate) gets pulled on by the powerful calf muscles during running, jumping and cutting activities, and becomes injured. The condition usually occurs in girls 8 to 10 years of age and boys 10 to 12 years of age.

Figure 1.

CAUSES

Injuries are usually the result of overuse, especially during a rapid growth spurt and may result from:

• a sudden increase in intensity, duration or frequency of sports or exercise
• beginning a new sports activity, especially an activity involving running, jumping, cutting and side-to-side motion
• tight hamstrings (the large muscles over the back of your thigh) and tight calf muscles and tendons
• high arches or flat feet
• direct trauma or injury to the heel.

SYMPTOMS AND SIGNS

• You will have pain over the bottom of the back of your foot and heel.
• You will have pain with weight-bearing activities, running, jumping and standing on hard surfaces, especially for long periods of time.
• You may have pain when you walk on your toes and when you walk barefoot.
• Pain may be relieved with rest off your feet or with wearing shoes with good support.

Swelling, redness, numbness, night pain or pain directly under the middle of the heel bone do not usually occur with Sever's disease and imply that something more serious may be causing your symptoms.

WHEN TO CALL YOUR DOCTOR

Call your doctor right away (day or night) if:

• You develop significant heel pain and swelling after an injury or fall on your heel or foot.
• You have heel redness and warmth with swelling and/or fever.
• You develop pain in your heel that awakens you from sleep.
• Your heel pain has become more constant and is getting progressively worse with weight-bearing activities, especially walking and running.

Call your doctor during regular office hours if:

• You have heel or foot numbness, tingling or loss of sensation.
• You notice that other joints are painful and swollen.
• You have had a recent puncture wound to the heel.
• You have heel pain that fits the description of Sever's disease (above, in SYMPTOMS AND SIGNS) and that does not start getting better over one week or does not completely go away by two to three weeks with the self-care measures listed below.

SELF-CARE AT HOME

• Avoid any activities that worsen your symptoms until you have minimal heel pain. These may include sports or exercise that involves running, jumping and cutting.
• Stay active using non- or low-impact exercise activities such as swimming, rowing, bicycling, or elliptical trainer or glider until your symptoms are minimal or resolve.
• When you have minimal or no heel pain you may gradually return to impact activities such as running.
  • Run or walk on soft surfaces such as tracks or trails.
  • Use walk-run intervals to get back to your previous level of exercise.
  • You may want to start intervals by walking for four minutes, jogging for one minute and repeating three to four times.
  • You can gradually decrease the amount of walking and increase the amount of jogging until you are jogging for your entire workout, then increase jogging time gradually.
• Stretching exercises that stretch your heel tendons and the bottom of your foot should be performed daily, held for 30 seconds, and repeated three times each.

Heel tendon and calf stretches

• Calf stretch: Take the position in the picture labeled calf stretch (Figure 2). Lean forward toward the wall while keeping your back leg straight to feel the stretch in your calf muscle.
• Heel tendon stretch: Take the position in the picture labeled heel tendon stretch (Figure 3). Lean forward toward the wall while keeping your back knee bent until you can feel the stretch over the back of your ankle.

Arch and plantar fascia stretches

• Step stretch: Stand with the ball of your injured foot on a stair or step (Figure 4). Drop your heel toward the floor while bending your knee forward until you feel a stretch over the bottom of your foot.
• Angle-board stretch: Prop one end of a small piece of plywood up on a two-foot length of two-by-four-inch board to make an "angle board." Nail the plywood to the two-by-four. Place the setup near a wall and stop onto the board. Place your hands on the wall and, keeping the back of your knees straight, lean forward toward the wall until you feel a stretch over the bottom of your foot.

Hamstring stretch

• Lie on the floor on your back. Straighten your leg and place a towel or a piece of rope around your foot and pull your leg toward your head (Figure 5) until you feel a stretch over your injured hamstring.

Figure 5.

• Place an ice pack or cold pack directly over the injured area of your heel. You can hold it in place with an elastic wrap.
  • Use the cold pack for 20 minutes at least three times daily or more often if needed to reduce pain and swelling.
  • If you are not wearing an elastic wrap directly over your skin, place a thin washcloth between the cold pack and your skin to reduce the risk of frostbite.
  • If you are busy, you may choose to ice during meals so as to save time and avoid interrupting other activities.
• You may take acetaminophen (Tylenol®) if you need it occasionally for pain. (See label for dose and risks.)
• An over-the-counter gel heel cushion (Figure 6) should be placed in shoes to support your heel and to reduce symptoms.

Figure 6.

• Wear a night splint or sock that stretches your foot and heel while you sleep (www.thesock.com/ or www.plantarfasciitisbrace.com/). When you sleep, your foot falls into a pointed-toe or plantar-flexed position, which shortens the heel tendons. The sock or splint helps prevent this by allowing stretching the tendons while you sleep.
• Avoid walking barefoot and wear good-quality athletic shoes with the added cushion or support until your symptoms resolve.