Current Insights on Conservative Care for Heel Pain

Heel pain in children is commonly caused by calcaneal apophysitis or Sever’s disease. This is a traction apophysitis at the calcaneus due to the pull of the Achilles tendon insertion and the origin of the plantar fascia. Typically, the child is involved in a youth sport or activity, such as soccer, baseball, track or basketball, which involves a lot of running and jumping.

Usually, the condition will resolve on its own over time but it is helpful to treat symptoms in the active child using many of the aforementioned treatments such as taping, proper shoe recommendations, ice, stretching (not during acute episodes), etc. I like to apply a low Dye strapping with a closed basket weave on the heel. This has worked very well in allowing children to participate in their activity relatively pain free.

Institute a stretching exercise program for the Achilles tendon and plantar fascia when the child is not in a pain cycle. Addressing footgear is also critical in allowing the child to return to activity and reduce symptoms.

During the exam, the child with calcaneal apophysitis will have a positive squeeze test with medial and lateral compression over the heel with localized tenderness. The activity level is based on response to treatment and minimizing pain with activity.

Keys to Ensuring a Good Fit with Athletic Shoes
• Measure both feet standing on a Brannock device.
• Have patients try on shoes in the afternoon or evening due to swelling.
• Have patients wear similar weight socks or orthotics for activity.
• Have patients try on shoes a half size larger to compare fit.
• Do the basic three shoe tests to evaluate quality.
• Tell patients there should be at least one finger width from the end of the longest toe to the end of the shoe.
• Have patients wear new shoes indoors first to make sure they are comfortable.
• The shoe should not require a break-in period.
• Educate patients on knowing when to replace shoes and the differences among shoe brands.

Treating heel pain can be a real challenge. It is very important to get a detailed history from the patient as to the etiology of the heel pain. The vast majority of heel pain results from overuse. When acute injuries become chronic, one should identify and address biomechanical causes. Evaluating the patient’s training, shoe gear and any previous treatment is essential to a successful treatment plan.

Commonly, the diagnosis points to plantar fasciitis. However, remember there are many causes of heel pain and your differential diagnosis could include a calcaneal stress fracture, nerve entrapment/neuritis, calcaneal apophysitis, calcaneal bone cyst, Reiter’s syndrome or a possible tumor. A good history and exam will help pinpoint a diagnosis and direct a subsequent treatment plan.
Heel pain in the athlete is commonly caused by an increase in the intensity and frequency of activity. Often the athlete is adding running to the workout routine and for cross-training workouts. A good history will include the following key points: sudden or gradual onset of pain, localized or diffuse pain, pain intensity (scale of 1-10), duration of pain and what relieves the pain. The patient history also includes any prior history of problems, any previous treatment, any changes in training intensity and frequency, and any changes in athletic footwear.
The problem with using the pain scale is getting the patient to understand the relative number as most patients will say it is a 10. It is sometimes difficult to determine if the pain is mechanical or neurological in nature. Commonly, the pain is insidious in nature and there is no incidence of trauma.