Plantar heel pain in child

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Hi all,

I need some ideas and advice for a
- 9 y.o female. Very active.
- Ballet 2 hours per week ( no pointe yet)
- oz kick 1 hour per week
- swimming 1 hr
- no prior developmental probs

Pain of medial tubercle of calc on R foot Hx 3 months. Present at a variety of times including 1st in the morning. But sometimes throughout the night. Inc severity after WB activity.

On stance R foot everted aprox 5-10 degrees, in gait there is and abductory twist on both. Non WB exam, foot is flexible, position able to be corrected.

On first exam I taped w low dye taping and a j-strap. No releif from pain.
My thoughts were then on a tarsal coalition??
Plain films reveal nothing.....:wacko:

Any other ideas to get my mind working.
Thanks,

Sally

 

Sounds to me like Sever's of the R heel?

Increased pain directly after activity? Pain on medial tub of calc or post inf calc?

Try some cushioning or silicone heel cups.

 

What views in the plain film? How did the Syme line look in the lateral view. No halo sign? Did you try a Harris a Beath? Still thinking coalition then CT is the way to go.

How long was it taped for? But if no relief from a week or so I would go further investigation. Ultrasound for plantarfascitis or CT for coalition.

 

Sorry, for some reason I can't edit the post. I did mean to add that if the pain is plantar, I would be thinking overuse if posterior, severs.

 

the growth plate can often be tender plantarly with severs, just often overlooked.

As for tarsal coalition, X-ray will only show osseous coalitions, not the fibrous/cartilaginous coalitions so MRI would be useful assuming the foot has accompanying stiffness/spasm.

Just my two cents

 

Can you post the X-rays Sally?

Cheers!

 

Thanks for all your feedback guys. MeltonFC my diagnosis had swayed away from severs as poterior calc was not painful, and compression of post calc did not cre3qate the pain...however, not ruling it out.

I am aware of the limited visibility of coalitions on xrays, however in this case, MRI was not appropriate due to financial issues.
With second opinion of the films, it is posible that there is a fibrous coalition of the talo-calcaneal.

I will try to post xrays for you to see, please offer any opinions.

Regards

Sally

 

Hi Sally,

Sever's can also be palpated plantarly... have you assessed the patient for ankle joint dorsiflexion stiffness? If coalition is ruled out on xray, I'd also be suspicious of achilles tendinopathy, because the undamaged fibres of tendo achilles can still extend quite distally/plantarly in a juvenile foot...

If you haven't already tried, it's probably worth trying heel raises for this patient, to see if this helps to decrease the tensile strain through the achilles tendon and posterior heel... the low dye tape might have been too difficult for the patient to tolerate if there is a significant equinus present, you could try tape plus heel raise to see how this goes

Keep us posted with how the little one goes...

Regards

Donna

 

any good tips for scanning the xrays? they come out black

 

Sally:

You can use a digital camera to capture an image of the x-rays while they are illuminated in the x-ray viewing box. This has worked well for me. I've tried scanning x-rays before but have never managed to figure out how to correctly do it.

Regards,

Dan

 

Sally:

This should be considered to be Sever's disease unless proven otherwise. Sever's disease often causes plantar heel pain. Your patient could also be suffering from a plantar heel contusion due to the impact activities with little calcaneal padding, which is also relatively common. You must remember that many cases of plantar heel pain in both adults and children are caused by compression forces from ground reaction force and the impact of being barefoot or shoes with little calcaneal padding on hard surfaces. If she is doing barefoot sports such as gymnastics or martial arts, I use a Tuli's Cheetah heel protector that works very nicely. If all else fails, have her do no running/impact sports for a month and she will likely be healed.

 

She is a little on the young side for Severs, and plantar heel pain is less common... however a wise man said to me once- 'an unusual presentation of a common problem is more likely than an uncommon problem'
Therefore I agree...

With respect to a coalition- you can usually feel the restriction in ROM-
As for management, I think it was mentioned above- try a low dye tape- but not too tight posterior heel- and combine with a heel raise.

 

Thanks for all the advice. It is all most valuable. I am reviewing her tomorrow so will inform of the progress

 

On review, pain still persistant.
Treated as per severs + plantar heel contusion. I taped her up, added a cushioned heel pad,
No dancing, only swimming for 2 weeks, Not to go barefoot at home, wearing crosstrainers to school.

Review in 2 weeks.

Thanks all for your help.

Sally

 

According to notes by one C. Payne...Sever's usually occurs between the ages of 8 to 15 years with a peak incidence around 10 to 11 years.

 

Is this a referenced set of notes?
My post said that it is a little on the youing side- not that it did not occur...
I would say the most common Severs patient is male aged 11-13 and very active. I am basing this on my 15 years of experience... do you have a different view with your clinical experience??

Now THAT is young...
It sounds like a case of giving heel pain a name- along the line of 'metatarsalgia'.

 

Hi again Sally, sorry there has been no resolution yet. Any luck with scanning the x-rays? Maybe time for a referral for further radiological investigation?

 

This was the first review after xrays were taken, So i was expecting pain to still be the same.
The Xrays did reveal a couple bone cysts in the calcaneus, perhaps in a reaction to pressure. No coalition. This is inline with what Kevin said.
After discussions with child and mother, it was found that she was often running/dancing around with barefeet on the tile floor. She also dances and shoes have very little heel support or cushioning.
Although she had bought in a good little pair of asix crosstrainers, she doesnt seem to wear them all that much.
There very well could be elements of severs going on also.

So as my treatment outlines above, there should (hopefully) be releif whether Severs or just bone bruising. Review 2 weeks

And yes Bug [/QUOTE]Maybe time for a referral for further radiological investigation?[/QUOTE]
If there is no reduction in pain, then definitely a need for further examinations.

Regards
Sally

 

Sally:

With the additional history provided above, think "bone bruise" on plantar calcaneus due to excessive plantar medial tubercle compression loading forces on hard surfaces. She will need 2-6 weeks of heel protection (as you have already recommended) to become asymptomatic if this is the case. Don't need to send this one out for referral...you're doing just fine.

 

Kevin,

Do you (or does anyone) know of a source of Tuli's Cheetah heel protector (or similar) in the UK?

Many Thanks

Ian

 

Sorry, no.

 

What about:
http://www.healthmatters4u.co.uk/tulis/10260.html?

:drinks

 

Patient returned for reveiw today (2 weeks)
- Pain had subsided for about 10 days, then recurred and patient was crying in pain.
- Compliance with heel cup/cushion and footwear, has not been attending dance classes and wearing shoes at home, however, as a 10 year old she is still fairly active and jumping about alot
I have referred for an ultrasound to rule out anything else going on in the area...but am puzzled as to wear to go next??? Plaster Cast?

Any ideas will be enthusiastically appreciated

Sally

 

CT/MRI?

Poor thing - both of you. Nothing worse than a kid in pain and not being able to fix it.

I'd go Camwalker with an arch filler before plaster if you don't know what it is.

 

You mentioned that she is 5-10 deg everted on the right... does that mean she is better on the left??
If she is asymmetrically pronated and symptomatic on the worse side, I would try the tape again with a heel lift- make sure not too tight posteriorly. Or an OTC ortho perhaps with a heel lift...

 

Sally:

It seems that she was getting better, then probably worse again due to increased activity. At this point, I would put the child into a below knee fiberglass walking cast for four weeks and then expect 4 more weeks of no running or jumping after that she is removed from the cast. Some children just won't slow down until they are casted.

Hope this helps.

 

Ultrasound was undertaken with no abnormalities seen.

Patient had a review today (6 weeks since last appoint).
I had left her with the instructions of:
- Reduction in activity (although she is one of those hyperactive kids that WILL NOT SIT STILL!
- Tulli heel cup
- cross-trainers only, NOT ballet shoes or volleys
- to keep a pain diary.

Pain had been significant atleast every 2nd day. At various time of the day, not always preceded by activity. sometimes during night .

Im stuck.

I could cast her (or CAM WALKER) but what if after the 4 weeks it was actually a biomechanical problem and therefore I have not addressed the cause.

Or if I get her in orhtotics as she has some rearfoot pronation/ perhaps severs/perhaps plantar fascial inflammation? and it is actually a "bone bruise"??

Any advise will be valued.

Thanx

 

I'm still sticking with ruling out via CT/MRI or maybe give one of your surgical/paed collegues in Melbourne a look at the plain films to make sure there is nothing little that may be overlooked.

At least if you have ruled out everything then you are casting to relive muscle overuse rather than something underlying.

If she is hyperactive I would cast over CAM walker due to compliance however would be cautious about casting without knowing exactly why I am casting.

 

Just remembered this old threat.
Well I ended up putting a half plaster cast on and put her on crutches for 4 weeks (with a review and cast change at 2 weeks).

Pain was minimal over this period as expected, and 2 weeks post review pain had still not come back.

If nothing else it would have slowed her down a bit. She was very hyperactive and nothing else would keep her off it.

Disappointed I never could make a pinpoint diagnosis, but I feel it was probably bone contusion as Kevin said.

Good result in the end.

Thanks for all those who contributed

Sally Belcher

 

Sally:

Thanks for the follow up on your patient. This is very helpful for all of us who are following along.

In reviewing the responses made to you regarding possible diagnoses and treatments for this patient, I am again reminded of the old adage I was taught by one of my clinical professors at CCPM, "When you hear hoofbeats, think horses, not zebras."

 

I have worked in full-tine MSK work for 5 years now, and part-time for 10.

The first 5 years I was frustrated as I didn't seem to be able to accurately Dx some of the conditions that presented to me.
The last 5 years have taught me that common conditions are common, and arrive everyday, but those common conditions each have subtle differences from each other.