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. Children who are at risk for this condition are those who have biomechanical foot imbalances and are engaged in high-impact activities during periods of rapid growth. Further, the ever increasing numbers of children participating in organized sports activities make the occurrence of micro-traumatic and overuse syndromes of the foot increasingly common. Pointers For Detecting Calcaneal And Stress Fractures Calcaneal fractures are most common in children between the ages of 6 and 15. In young children under 10, the fracture may result from a jump or fall from a couch or stairway as little as two or three feet off the ground. In pre-adolescents and teenagers, the fracture usually results from a fall from a greater height.8 Extraarticular fractures of the calcaneus are twice as common as intraarticular fractures in the child.9 In addition to the history of trauma, patients who have calcaneal fractures may present with a limp or a refusal to walk or bear weight. These patients usually present with pain while weightbearing as well as at rest. Be aware that calcaneal fractures are easy to miss on initial radiographs as fracture lines are subtle and the fracture is commonly nondisplaced. When you suspect calcaneal fractures in children, be sure to get calcaneal axial, oblique and lateral radiographic views. Obtaining a bone scan may be necessary in order to find an occult fracture, which is sometimes referred to as “another toddler fracture.”10 These fractures are most often successfully treated with nonweightbearing immobilization for at least four to six weeks. The prognosis for these fractures is good, even if they are intraarticular.8 The elasticity and subsequent remodeling of bone make calcaneal fractures in children less complicated than in adults. In select cases, with comminution or severe displacement, one may need to employ open reduction and internal fixation in order to reduce and stabilize the fracture as well as to decrease the likelihood of secondary deformity and posttraumatic arthritis.11 Stress fractures of the foot are less common in children than in adults.12 Approximately 2 percent of all stress fractures in children are in the tarsal region.13 Children at the highest risk for these injuries are skeletally maturing adolescents in the early stages of training and sports participation. Symptoms of calcaneal stress fractures include pain on weightbearing and the absence of or a marked reduction in pain at rest. While these patients will have usually have local tenderness, you will find that edema and other cardinal signs of acute injury are often absent.11 Radiographs will show periosteal new bone formation approximately two weeks after injury. Be aware that prior to this time, plain film radiographs may appear negative. Employing scintigraphy may aid in making an early diagnosis. Successful treatment is usually a short (two- to four-week) course of immobilization with limited weightbearing. An Overview Of Inflammatory Conditions Achilles tendonitis is a common inflammatory condition of the heel that one will often see in older adolescents.14 Risk factors include gastroc-soleus equinus, a recent growth spurt and participation in sports such as gymnastics, basketball and running with high sagittal plane stresses on the ankle. Successful treatment includes structured stretching of tight structures, heel raises, antiinflammatory medications and the use of foot orthoses when the patients has other biomechanical imbalances. Immobilization is rarely necessary except in severe, acute episodes. You should also consider posterior tibial and peroneal tendonitis in the differential diagnosis of inflammatory heel pain in children. The location of the symptoms should aid in diagnosing regional tendonitis. Also consider plantar fasciitis or insertional heel pain at the inferior calcaneal insertion of the plantar fascia when the patient has localized pain to this anatomical region. If you encounter abnormal pronation in a flexible, acquired or congenital pes valgus or flexible cavus foot with alteration on weightbearing, consider these as significant contributing factors to the development of this disorder. Retrocalcaneal bursitis is characterized by inflammation of the retrocalcaneal fat space deep to the tendon at the posterior dorsal part of the calcaneus. It can be difficult to distinguish from Achilles tendonitis. The second bursa in this region is the Achilles bursa, which is superficial to the tendon and located distal to the retrocalcaneal bursa at the insertion of the tendo-Achilles. Typical symptoms include localized pain to the posterior heel. The pain is exacerbated by activity such as running and jumping, and relieved by rest. Radiographically, this condition is characterized by loss of definition of the retrocalcaneal recess, which lies between the retrocalcaneal bursa and the Achilles tendon insertion. There is usually an absence of associated superficial soft tissue swelling, Achilles tendon thickening or cortical erosions of the posterior calcaneus.15 One will find tendo-Achilles bursitis superficial to the tendon at the insertion. It forms in response to chronic irritation and appears radiographically with localized swelling and convexity of the soft tissue superficial to the tendon insertion. In treating retrocalcaneal bursitis, you want to reduce inflammation and chronic irritation. Treating Achilles bursitis is similar but a key objective is eliminating the direct friction irritants of the posterior heel. Detecting And Treating Spondyloarthropathies Enthesopathy is an inflammation of the cartilaginous attachment of ligaments and tendons to bone. When you see it in a child’s heel, you should consider the possibility of juvenile-onset seronegative spondyloarthopathy. Spondyloartropathies are interrelated syndromes not associated with rheumatoid arthritis. They often have similar clinical presentations and are commonly associated with the genetic marker HLA-B27.16 Examples of spondyloarthropathies include ankylosing spondylitis and Reiter’s syndrome. Typical locations for enthesopathies in the foot include the Achilles tendon and plantar fascia insertions into the calcaneus. In the case of the plantar fascia, symptoms are typically located at the medial insertion of the fascia into the calcaneus with post-static dyskenesia as a complaint. Boys are more likely to be affected by juvenile seronegative spondyloarthropathy.17 Radiographs of the heel in patients with spondyloarthropathies will show periostitis, osteopenia, calcaneal erosions and bone spurs.17 One would emphasize conservative treatment for these conditions. In addition to having the patient reduce his or her precipitating activity, one may also employ nonsteroidal antiinflammatory medications and therapeutic stretching. It is often beneficial to use orthoses to manage concomitant biomechanical imbalances and provide soft tissue supplementation. Studies have shown that about 25 percent of young patients with spondyloarthropathy or with peripheral arthritis and HLA-B27 had a history of heel pain.18 In another study, the heel was the most common site of enthesopathy in children with seronegative enthesopathy and arthritis.19 How To Address Juvenile Rheumatoid Arthritis When it comes to juvenile rheumatoid arthritis, one will most often see this condition in children between the ages of 6 and 14. Juvenile rheumatoid arthritis is seronegative and typically affects large joints.20,21 There are three classifications of this disease and any of them may affect the tibiotalar or subtalar joints. Ten percent of these patients may have the systemic onset form, which is known as Still’s disease. This is marked by fever, rash, splenomegaly, tenosynovitis, myositis and polyarticular arthritis. The polyarticular form involves more than the four major joints. The oligo- or pauciarticular form is the most common and involves four or fewer joints.20 When there is persistent arthritis of one or more joints for a period of more than six weeks, one would make the diagnosis of juvenile rheumatoid arthritis after excluding other forms of childhood arthritis. The polyarticular and systemic forms are more likely to include small joint involvement. Symptoms are usually bilateral but not necessarily symmetrical.20 Lab work usually reveals an elevated ESR. Rheumatoid factor is typically negative except in the small number of cases with the polyarticular form. Antinuclear antibodies may be present in the pauci- and polyarticular forms. Keep in mind that you may see abnormalities associated with systemic disease, such as elevation of the white cell count and anemia, in patients with Still’s disease.21 Early radiographic findings include osteopenia at the metaphysis, soft tissue swelling and periosteal reaction. In the intermediate stage, one may see cortical erosions along with narrowing of the joint space. In the later stages, you may see joint ankylosis and deformity. Nonsteroidal antiinflammatory medications are the initial treatment. One may consider more potent pharmacologic agents such as gold salts and steroids in cases that are more difficult to manage. One should also manage biomechanical imbalances that may exacerbate arthralgias. When An Infection Causes Heel Pain Soft tissue infection with or without abscess is a possible cause of heel pain in the child. Cardinal signs of infection with negative bone involvement make up the typical presentation. Incision and drainage with appropriate oral or intravenous antibiosis are the treatments of choice. Making an early diagnosis of bone and joint infections in infants and children is essential in order to prevent permanent growth plate and epiphyseal damage. The extensive vascular supply to the metaphysis makes the hematogenous mode of inoculation more common in this population. Vascularity of the growth plate may allow for direct extension inoculation. The most common cause of osteomyelitis in the child’s foot is a traumatic puncture wound. Pseudomonas is the most common causative organism in cases of puncture wound osteomyelitis.22 Osteomyelitis caused by Group B hemolytic Strep and Haemophilus influenzae in newborns after heel puncture for blood sample occurs in 1 out of 30,000 cases.22,23 Meningococcus in infants and Staph aureus in toddlers and children are the most common pathogens causing osteomyelitis in these populations.11 Hematogenous osteomyelitis in the calcaneus typically occurs adjacent to the apophysis. The lesions appear as well-defined, round, lucent areas that are located centrally or peripherally in the bone. With healing, the lesions tend to develop sclerotic margins, gradually ossify and disappear.24 Be aware that you may get a positive bone scan before seeing changes on plain film radiographs. You should also obtain blood and bone cultures for diagnosis and in order to select an appropriate antibiotic therapy. The treatment is long-term intravenous antibiosis for six weeks with incision, drainage and curettage as needed.25 How To Treat Benign And Malignant Tumors Cystic lesions of the calcaneus are usually asymptomatic and are often incidental findings on X-ray. Microfractures can occur in the cyst and cause pain.26 Unicameral or solitary bone cysts are the most common tumor of the rearfoot in children.26 While other benign cystic tumors are uncommon, one should consider them in the differential diagnosis. These include enchondromas, aneurysmal bone cysts, eosinophilic granulomas, osteoid osteomas and intraosseus lipomas.27 One would usually locate unicameral bone cysts anteriorly and laterally in the calcaneus. The cyst’s radiographic appearance may be expansile, circumscribed by a thin sclerotic margin with little or no internal trabeculation.28 A normal anatomic variant, sometimes referred to as a “pseudocyst,” typically contains trabeculations and is not circumscribed by the sclerotic border.12 It is not routinely recommended to excise solitary bone cysts. If the patient is experiencing pain, emphasizing a reduction of activity with immobilization may be helpful. While percutaneous steroid injections, are effective for unicameral bone cysts elsewhere in the body, researchers have shown them to be ineffective in bone cysts of the calcaneus.29 In those symptomatic cases where conservative therapy is ineffective, surgical curettage with bone grafting is recommended.30 Osteoid osteomas constitute almost 4 percent of all bone lesions in the first decade of life.31 These are typically seen in the long bones, but when they are present in the foot, the most common location is in the talar neck.32 Characteristic symptoms include night pain relieved by salicylates, local tenderness and soft tissue edema. The radiographic appearance is also characteristic. The lesion is round and usually less than 1 cm in diameter. There is a central calcification that forms the heraldic nidus, which is surrounded by a radio dense border. With a bone scan, one will typically note a region of greater uptake in the center of the lesion surrounded by a zone of lesser uptake.11 Salicylates are the initial treatment. In resistant cases, surgical curettage with bone grafting is usually curative. Fortunately, malignant tumors are extremely rare in the feet of children.11 Synovial sarcoma is the most common malignant tumor one would see in the foot.33 Ewing’s sarcoma is the most common primary bone tumor you would find in the calcaneus.27 Up to 50 percent of Ewing’s sarcomas in the foot are found in the calcaneus.34 Other possible malignant processes that may involve the heel include leukemias and metastases from other primary tumors. A Guide To Treating Tarsal Coalitions Tarsal coalitions of the subtalar or midtarsal joints are in the differential diagnosis of rearfoot pain in the older child and adolescent. Pain, reduced range of motion, rigid rearfoot valgus and peroneal spasm is associated with this condition.35 The union may be osseous, fibrous or cartilaginous. The two most common coalitions are middle-facet talocalcaneal and calcaneonavicular bars. The most common calcaneonavicular coalitions tend to occur at a younger age, usually between 8 and 12.36 Obtaining a medial oblique view is the best plain film view and one may get added benefit in using computer tomography when necessary.37 Talocalcaneal coalitions are most common between the ages of 12 and 16 and you would see these coalitions more frequently in boys. There may be a family history with this condition as well. In diagnosing this condition, axial calcaneal and lateral X-ray views are helpful but computer tomography is often required to make the diagnosis. Conservative treatment ranges from activity modification with biomechanical orthosis therapy to immobilization for symptom relief and to break spasm after a peripheral nerve block. Keep in mind that many cases proceed to surgical resection of the bar with possible fat graft interposition at the excision site.37 Failed resections may go onto subtalar or triple arthrodesis. Final Words Pain in the heel is one of the most common sites of symptoms in the child’s foot. The child may present with a limp or other signs causing worry to the child and the family. Obtaining the history and performing the physical exam are important in the differential diagnostic process, but lab work, x-rays, scintigraphy, computer tomography and other imaging techniques may be necessary in order reach a definitive diagnosis. Dr. Volpe is a Professor in the Departments of Pediatrics and Orthopedics and Chair of the Department of Pediatrics at the New York College of Podiatric Medicine. He has a pediatric foot and ankle specialty private practice in New York, N.Y. and Farmingdale, N.Y. CE Exam 117 Choose the single best response to each question listed below: 1. Which of the following is a common finding in children with calcaneal apophysitis? a) Erythema b) Equinus of the ankle c) Osteochondrosis d) Edema 2. What diagnostic modality may be required to detect an occult fracture? a) Radiograph b) Scintigraphy c) X-ray d) Bone scan 3. Which Achilles tendonitis treatment is usually only necessary in severe, acute cases? a) Immobilization b) Heel raises c) Open reduction d) Antiinflammatory medications 4. Which of the following statements about retrocalcaneal bursitis is false? a) Typical symptoms of the condition include localized pain to the posterior heel. b) The pain is exacerbated by activity such as running and jumping. c) Patients with this condition have pain with rigorous activity and at rest. d) None of the above 5. Which of the following is a conservative treatment option for spondyloarthropathy? a) Orthotics b) NSAIDs c) Stretching d) All of the above 6. What condition may be present in the intermediate stage of juvenile rheumatoid arthritis? a) Cortical erosions b) Narrowing of the joint space c) a and b d) Joint ankylosis 7. Which of the following statements is false? a) Females are more likely to be affected by juvenile seronegative spondyloarthopathy. b) Soft tissue infection with or without abscess is a possible cause of heel pain in a child. c) Cystic lesions of the calcaneus are usually asymptomatic. d) One should use heel lifts and/or foot orthoses to help treat calcaneal apophysitis. 8. Calcaneal fractures are most common in children between the ages of … a) 9 and 13 b) 7 and 11 c) 6 and 15 d) None of the above 9. What percentage of Ewing’s sarcomas found in the foot are found in the calcaneus? A) 10 percent B) 70 percent C) 50 percent D) 30 percent Instructions for Submitting Exams Fill out the postage-paid card that appears on the following page or log on to www.podiatrytoday.com and respond electronically. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam. Responses will be accepted up to 12 months from the publication date.
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