The adult patient often seeks professional help with pain or discomfort in the foot. Pediatric consultations with a foot and ankle specialist are less often pain-related with concerns about gait or positional abnormalities more likely. When pain is the initiating complaint, it usually occurs in the child’s heel. However, the differential diagnosis of heel pain in the child can be challenging for practitioners. It may be difficult to obtain an accurate history from a child and parents are only able to relate what the child has told them or what they have observed. This can make differential diagnosis more difficult and practitioners may be frustrated as they try to manage a symptomatic child. With this in mind, let us consider the array of causes that can contribute to heel pain in children. What You Should Know About Calcaneal Apophysitis This condition is a traction apophysitis of the insertion of the Achilles tendon into the calcaneus.1 In 1912, Sever said this condition is not unusual in growing children but you would never see it after puberty. He considered it a muscle strain and suggested rest and protection to resolve the condition. He never stated that calcaneal apophysitis was an osteochondrosis, although other authors have classified it as an osteochondrosis.2,3,4 Calcaneal apophysitis is an overuse syndrome and is analogous to tibial tubercle apophysitis, which is also known as Osgood-Schlatter disease.5 The most common cause is repetitive microtrauma or overuse which leads to injury and symptomatology at the apophysis.6 Aggravating factors may include an imbalance between long-bone growth and soft-tissue growth, and limited dorsiflexion of the ankle.7 One study of 85 patients with calcaneal apophysitis found 75 percent patients were male and 25 percent female. Researchers found the symptoms were bilateral in 61 percent of cases and unilateral in 39 percent of cases.6 Typical symptoms include local tenderness in otherwise healthy children with no antecedent trauma. These patients are usually deemed to be in a growth spurt. In one study, 80 percent of patients said pain was worse after a specific athletic activity. The sport most likely to be associated with the apophysitis was soccer (29 percent), followed by basketball, gymnastics and running.6 A physical examination of the patients will typically reveal tenderness upon medial and lateral heel compression. There is usually no erythema, edema, dermatologic abnormalities or other local pathology. Equinus of the ankle is a common finding.6 Other biomechanical abnormalities found in patients with calcaneal apophysitis include pes planovalgus, midtarsal pronation, pes cavus and hallux abducto valgus.6 Tips For Treating Calcaneal Apophysitis The first step in managing this condition is having the child discontinue playing the impact sports that are aggravating the condition. One should emphasize the use of heel lifts and/or foot orthoses. Soft tissue supplementation with shock absorbing materials is recommended. One may achieve this by using a laminated device of more flexible materials or opting for a top-layer, soft tissue supplement on a more motion controlling shell or module. Employing deep heel seats to accentuate the natural effect of the anatomical fat pad of the heel will also yield improved results. Encourage these patients to wear these devices as much as possible and to limit the amount of time they are barefoot even at home. You should address sagittal plane muscle imbalances at the ankle with supervised therapeutic exercises. These should include gastrocnemius-soleus stretching exercises as well as dorsiflexion strengthening, preferably under the supervision of a physical therapist. In recalcitrant cases, immobilization with a short-leg cast or walker-boot for up to one month is recommended.4 Although the name apophysitis suggests an inflammatory process, it appears the most likely etiology is mechanical overuse that occurs during periods of rapid growth. Therefore, corticosteroid injections or oral antiinflammatory medication are rarely indicated. Keep in mind that this overuse syndrome, which responds well to physical therapy, improved foot biomechanics and soft tissue supplementation, may be preventable.