Growth plate injuries in children are among the most common foot and ankle injuries that present to a foot specialist’s office. These patients are often athletes and may or may not have a traumatic accident associated with the injury. When an adolescent or teenager develops ankle pain, it is often a repetitive overuse type injury.
Ankle injuries in children may result in a fracture, osteochondral injury or sprain if trauma is involved but more commonly, children develop an injury to their growth plate or epiphysis. The distal tibia epiphysis becomes more active at the age of 12 to 14 in boys and 10 to 12 in girls.1 The distal tibia growth plate completely matures at the age of 17 to 18.2 Children who are active in soccer, baseball and football may be more predisposed to overuse injuries in the distal tibia due to the lack of support and firmness of their cleats.
The purpose of this case study is to describe a common ankle injury that we often misdiagnose and to explain treatment protocols that may be very helpful to the treating practitioner.
A Closer Look At The Patient Presentation
A 12-year-old boy presented to the office with a chief complaint of severe right ankle pain. The soccer player first noticed the pain after a game three weeks prior to his office visit. He says he may have taken a “bad step” on the grass while running toward a ball. It did not affect his play at the time but he was limping after the game. The patient described the pain as aching and throbbing, and rated the pain at 6/10 on a 10-point pain scale. Home treatment included ice and rest but the pain continued to persist.
The physical exam revealed mild edema to the anteromedial aspect of the ankle joint with severe pain on palpation over the anteromedial aspect of the distal tibia epiphysis. There was mild pain with range of motion of the ankle joint and no pain with inversion or eversion of the foot. There was pain with palpation along the distal aspect of the Achilles tendon at its insertion, which extended 2 to 3 cm proximally with the knee in a flexed and extended position. The neurovascular status was intact. No gross deformities were present.
The biomechanical exam revealed an abnormal subtalar joint axis (too medially deviated). Bilateral ankle joint dorsiflexion was 10 degrees with the knee extended and 15 degrees with the knee flexed. The resting calcaneal stance position was moderately pronated (6 to 10 degrees of eversion) and the neutral calcaneal stance position was perpendicular bilaterally.
Plain films revealed an open distal tibia epiphysis and no signs of fracture or neoplasm. The patient was non-weightbearing with crutches in a pneumatic below knee controlled ankle motion (CAM) walker. We recommended ice and Aleve bid. The pain resolved after four weeks of immobilization. We cast him for custom functional foot orthotics to help control the abnormal pronation and prevent recurrence. He returned to playing soccer without limitations six weeks later. After two years of follow-up, he did not develop a recurrence.
What You Should Know About Growth Plate Injuries
Growth plate injuries in children will often prevent a child from participating in sports and may result in limping. This may lead to concomitant injuries as in this example of Achilles tendonitis secondary to distal tibial epiphysitis. Other possible secondary injuries that may occur due to limping may include plantar fasciitis and extensor or posterior tibial tendonitis.
Distal tibia pain is partially the result of abnormal biomechanics. In this example, the child had moderate calcaneal eversion of 6 to 10 degrees in resting stance and an abnormal subtalar joint axis. Some children may also develop distal tibial pain from mild calcaneal eversion of 1 to 5 degrees in resting stance if they pronate excessively in gait. The abnormal calcaneal eversion and pronation increase stress to the medial aspect of the ankle joint, which may lead to repetitive compression of the distal tibia epiphysis.
The first step in treating a patient with distal tibia epiphysitis is to resolve the inflammation of the growth plate. Pneumatic CAM walker immobilization is necessary with or without a gel heel pad. In our experience, if a child uses crutches, he is more likely to minimize weightbearing. Even if one advises patients to be non-weightbearing, they will likely walk on the foot. If the foot specialist does not believe patients will use the crutches, add a gel heel pad to the CAM walker to decrease pressure on the heel and ankle joint.
Once the pain has greatly improved, custom orthotics will assist the athletic child in returning to shoes and sports. We often recommend a deep heel cup of 18 mm and a 4 mm skive if there is an abnormal subtalar joint axis.3 We usually prescribe minimal cast fill for the pediatric patient.4 We typically invert the orthotic the same number of degrees as the calcaneal eversion (i.e. if the resting calcaneal stance position is 6 degrees of eversion, we will invert the orthotic 6 degrees).
Controlling the abnormal pronation by exerting greater ground reactive force medial to the abnormal subtalar joint axis and rebalancing the calcaneus as close to perpendicular as possible will help minimize stress on the distal medial tibia. This is essential in preventing recurrence of the injury in a child whose growth plate is still actively growing.
Dr. Feit is the President of Precision Foot and Ankle Centers. He is in private practice in Torrance and San Pedro, Calif.
Dr. Kashanian is in private practice in Los Angeles. She is a consultant for ProLab Orthotics.
Mr. Feit is a Research Assistant at Precision Foot and Ankle Centers.
1. Tax HR. Podopediatrics. Williams & Wilkins, Baltimore, 1980, pp. 56-58.
2. Tachdjian MO. The Child’s Foot. W.B Saunders Co., Philadelphia, 1985, pp. 42-43.
3. Kirby KA. The medial skive technique: improving pronation control in foot orthoses. J Am Podiatr Med Assoc. 1992; 82(4):177-188.
4. Scherer PR. Recent Advances in Orthotic Therapy. Lower Extremity Review, Lexington, SC, 2011, pp. 82-84.