Case study- The symptomatic Heel in a 12 year old

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This is the case of a young 12 year old boy who presents to the clinic with posterior heel pain. Upon examination no erethema or edema was found at the posterior and medial and plantar calcaneal areas. There was no pain upon placing stress at the medial and lateral calcaneus and at the distal insertion of the calcaneus. The pt states that he has was prescribed rigid off the shelf orthoses with dual-layers which has increased his symptoms in the last six months. He has a MRST of 3 and a jacks test of 15 deg bilaterally. He also has pes planu valgus and has a hx of this in the family according to the mother. He wears both soccer boots and normal shoes. The pt is active both in sports groups and at school.



What are the significant findings of the scenario?

What differential diagnoses can be drawn from this?

What orthoses prescription, given the history and circumstances would you implement?

What other treatment regimes will you consider in patient management.

 

What are the significant findings of the scenario?
12 yr old child- possibility of the apophosis still being present without fusion, increased levels of activity, high-density device has not worked in the past. No pain on normal sever's palpation, MRST relatively low, jacks test positive for FHL?

What differential diagnoses can be drawn from this?
Tarsal coalition - Middle facet STJ, calcaneo-navicular, acessory talus of the lateral process, calcaneal stress fx, congenital pes plano valgus,

Severs is highly unlikely but can be on the list at the end...


What orthoses prescription, given the history and circumstances would you implement?
Since dual density devices did not work - Go to single density first? And perhaps advise to buy dual-density shoes to increase SRF placed on the medial aspect. Heel lifts and varus posting.Then if that is not useful move to a custom device with heel lift, medial skive 15 deg 6 mm, VR posting.

What other treatment regimes will you consider in patient management.

RICE
Shoe advise
Activity reduction
Stretches of the achiles complex.

Also point to note - Would a first ray-cutout be warranted, or would you expect RF control to also address out forefoot pathology?

 

Got to ask -

what is a MRST ?

and a Jacks test of 15 degrees I know the Jacks test and use this " measurement "to gauge the dorsiflexion stiffness at the 1st MTPJ, but 15 degrees of what, where why and who ? Doesn´t make much sense.

Also have had Xrays ?

can you be more specific with your presentation of patient - this might help. http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=22144

ie how long have they had pain ?

what activities bring on symptoms ?

type of stuff.

 

I would say that Severs would be at the top of my list. What else would be the most likely in a 12yo boy playing soccer who has pain in the posterior calcaneus?

The posterior calcaneus is a long way from coalition territory...stress # maybe.

Who says he needs orthoses. Make the diagnosis first. It could be an osteosarcoma for all we know.

Ditto.

Be confident that you have made an accurate diagnosis first. That's the challenge.

The treatment bit is usually the easy part.


LL

 

Thanks for the input.

My apologies, I shall be more thorough with my explanations in the future. Jacks test, as all clinicians should know, as far as my knowledge extends measure Hallux dorsiflexion, so any association with any other movement regarded with the Hubsher technique is arbitrary. And thus the 15 deg is 15 deg of dorsiflexion. And my apologies, MSRT- Manual supination resistance test.

Pain has been present for over a year and has worsened since the use of off-the shelf dual density devices in the past 6 months. No x-rays were taken. Any type of sporting activity beings on pain as well as excessive time spent weight bearing.

General question- If the use of dual density orthoses have increased the patients symptoms, will clinicians be inclined towards trying a lower-density orthotic or be likely to move towards a custom-orthotic with equal or more control as the dual density EVA device?

Kind regards,

Shalom.

 

Ps- The possibility of a coalition is nill you say? How often would you not attain pain on palpation of the calcaneus in severs in that case? And yes I agree, for all we know can be some sort of bone lysis, osteomyelittis or even transient synovittis, or even an osseous growth.

 

Why is the degree of dorsiflexion of the 1st MTPJ important ie it´s not. I bet you with enough force I could get every patient to a dorsiflexion measurement of greater that 15 degrees - the results of a Jacks test is more in-tune with force required to dorsiflex the toe - or dorsiflexion stiffness.

Arbitrary findings of easy, moderate or hard give meaning to the test not a degree measurement ( which will be horribly inaccurate anyway ) .

 

A moderate amount of force was needed to dorsiflex the Hallux. The efficiency of this method of dorsiflexing the Hallux in static stance has very low-co-relation towards what the dynamic function of the Hallux in terms of the windlass is. Therefore, what you are actually measuring is not whether a functional block exists, but rather that there is an excess amount of force needed to dorsiflex the Hallux, most likely due to a medially oriented STJ axis, which you could have speculated with conducting a physical observation of the patient.

More important is the question of whether a reverse morton's extension, or a first-ray cut out would still be used amidst controlling rear-foot motion with an ORF, to counteract the STJ pronation moment?
What are your deductions?

 

So you are referring to the fact that with the use of force, Ie- increase the amount of first metatarsal plantarflexion, by excessively dorsiflexing the Hallux, that you are able to achieve more than 15 deg of Hallux DF. In other words, any force or facilitatory component of force that will increase the DF moment of the hallux or increase the PF moment of the 1st metatarsal in the propulsion phase of gait will act to benefit this stage of gait. Whats not to say the dynamic nature of gait calls for a patient to do this on their own?

 

No I didn't.

I said posterior heel pain is a long way away from the (usually middle facet) subtalar or calcaneonavicular sites.

Besides, your initial examination should have brought up an issue with ROM in the hindfoot or rigid flatfoot - so coalition can almost be excluded if these findings are normal.

And yes, sometimes I cannot palpate a whole lot of tenderness with Severs...

Occam's razor.

LL

 

Thanks Mr.Lisfranc, perhaps then this i another sever's case then. What say you about prescription variables in orthoses both Custom and non-custom in the treatment of severs?

 

Shalom,

the Dorsiflexion stiffness at the 1st MTPJ and all MTPJ´s will and must change over the course of gait, increasing and decreasing dorsiflexion stiffness will have specific functions and timing, if the stiffness is too high or too low at the wrong stages of gait there maybe a cause of pathology found which can be contributed to the wrong level of dorsiflexion stiffness at the MTPJ´s .

Stj pronation (kinematic change) will be one cause of a change in dorsiflexion stiffness yes , but there are others.

But once again 15 degrees is not a measurement I would recommend using when describing the results of the Jacks test - Stiffness is the key - yes it´s a guide but all measurements taken static are when we consider dynamic function.

 

Thanks Mike. So in this case, what is the justification for the use of methods to facilitate 1st MTPJ ROM, Ie- perform a static test - obtain whether there is stiffness or not (presumably in the mid-stance phase of gait, as we are doing a bi pedal stance assessment). And then prescribe either a first-ray cut-out or a reverse Morton's extension? If you so say yourself that the DF stiffness of the 1st MTPJ changes over the course of gait and at specific times is required to be stiff and at other times it is not?

Please elaborate.

Shalom.

 

Just so Robert and Robin laugh - Depends ( a bit of a Arena joke)

It not specific enough yet to say this is good this bad and dynamic function re stiffness at the MTPJ´s which why diagnosis and the use of mechanics to build you treatment plan it the way to go.

So say we have plantar fascia related problems, ie too much tension in the plantar fascia. We note an increased dorsiflexion stiffness at the 1st MTPJ at midstance, we can say that this static midstance measurement indicates that the dorsiflexion stiffness at the 1st MTPJ during gait will be increased and thus harder for the body to engage the windlass mechanism.

So the build our device to add this, we would look at the cause of the increased tension in the fascia - which is also the cause of the increased dorsiflexion stiffness at the 1st MTPJ and design our device.

Medial skive
increased arch profile
FF valgus post/reverse mortons extension
Cluffy wedge

Type of idea

But just like amedial deviate STJ axis the axial position will change during gait, but generally a medial deviated axis static measurement will indicate a medial deviated axis during gait.

 

Hi Shalom
Just a quick couple of points with this...
I agree with LL- Sever's would be the number one suspect- an unusual presentation of a common condition is more likely than an unusual condition. However you would want to rule out other more sinister pathologies simply based on the fact it is an unusual presentation. ie: imaging.
You stated...

I am assuming that you have seen this device- can you give us more information?
Just because a material is soft, does not mean that it cushions. Sever's tend to be sensitive to plantar pressure so a poor fitting orthosis can irritate even if it has a soft top on it.
Cheers

 

Agreed. This particular device was an off the shelf dual-density device that was heat moulded and bulk added to the arch with a VR rearfoot posting used. The top cover was a multiform cover approx 2mm with a heel raise of 8-10mm.

Shalom.

 

OK, so if you look at your Ddx of posterior heel pain in this age group:

Severs'
Juvenile idiopathic athritis/infective athritis
Tarsal Coalitions
Achilles Tendonopathy - yet, kids get it
Osteomylitis
Bone tumour


You keep jumping to treatment with type orthotic and yet you still aren't sure of the diagnosis.

Yes, it is probably Sever's but at the same time, it is atypical so imaging and a better medical history is in order. Is there is a history of cold/flu symptoms, other joint pain etc, is there a history that tells you to check the neurological signs, kids with CP or genetic conditions get sever's type pains when there are biomechanical issues that cause muscle issues that are controlled by the brain or localised muscular changes.

I would stop trying to work out a prescription and try and probably diagnose what you are treating. That will then give you a better indication of what to do.

 

:good:What she said

 

After receiving X-rays today, they are negative for any coalitions or any osseous growths that should not be there. The calcaneal apophysis is still present and does not appear jaggered, but is sclerotic. As we know from the literature though, the sclerosis does not say much as this is also present in the non-symptomatic child with an apophysis. There is no mention of infection in the last 6 months, no presence of osteomyelittis. So the only real structure of concern is the achiles tendon and the pes plano valgus that is causing him to excessively pronate his feet in stance or RCSP, which ever you fathom.

Now having done all this, how does this change the course of action? Most podiatrists would be inclined to place a child straight into an orthotic despite what the actual diagnosis is and I'm glad that you all were able to be stern about a diagnosis prior to this. So now that we have an exclusion of certain conditions, how would you proceed may I ask?

Ps- Pt returned after initial heel lift's mentioning that he felt a lot better walking but was getting pain in running and when participating in sports.

 

Thanks Mike, makes sense.

 

Shalom

Just to confuse you, read Is Sever's Disease a Stress Fracture?

My current thinking is that some kids fall into stress fracture territory, some fall into true tractional apophysitis.

A bit like fasciitis, ask him if it hurts when the heel hits the ground (stress/impact) vs coming off the ground (traction). Treat accordingly.

I rarely use orthoses for Severs' as in its pure form it is a purely sagittal plane problem that almost universally improves with higher heeled shoes and heel lifts/stretching.

LL

 

Thanks for that LL, thats just the answer that I was after.

Also, the thinking that it is a stress reaction/fx compared to a tensile loading injury does not alter its treatment of rest, reduction in activity, heel lifts and stretching. Stess fx, within given circumstances should take 6 weeks to heal, yet some Severs durations are more than 6-9 months, which is interesting. However, there has been cases where a four week casting procedure, done by orthopedic surgeons has also healed the condition. Just food for though.

Kind regards,
Shalom.

 

Not that I necessarily disagree with LL but if the feeling is that it it's a traction apophysitis, then the coronal and sagittal plane components may become more significant as they may increase the load on the tendo-achilles. On a handful of occasions where the usual ice, no barefoot, activity modification, heel raise (with and without cushioning) and footwear advice has not been enough,i have used orthoses to reduce pronation moments subsequently reducing the TA load. Generally has the desired effect but there have also been a few cases with limited resolution. I don't necessarily think the cushioning is hugely important.

Just my experience but read all of the severs related threads on here, they all have valid info.

Robin
.

 

Indeed.

This needs to drummed into an alarming amount of practitioners, and not just in relation to orthoses prescription.

Cheers,
Bel

 

What She said

what He said was a good idea

what She said indeed too

 

Have you tried low-dye taping? Bear in mind it can cause irritation if too tight around the posterior calcaneus...

 

Yes tried low dye strapping today, going to see how he responds to that. What have been your experiences with low-dye strapping?

 

I find taping useful to identify the forces which are likely leading to the pathology. You can tape, tape and heel lift or heel lift on its own. Assuming that you do note tape too tightly around the posterior heel, you can get a very useful amount of feedback as to what may help.
Often it makes a very significant difference to pain levels.

 

And what exact mechanisms do you propose for the controlling of forces with low-dye strapping?

Shalom.

 

Taping and Sever's Disease

 

Here's my take on this thread....any time I see a boy or girl (ages 8-12) with posterior-plantar heel pain with running and is active in running sports, I assume it it Sever's disease until proven otherwise. Heel lifts, icing, calf stretching, avoidance of low heeled shoes and avoidance of walking or running barefoot is initial treatment. Custom foot orthoses (I prefer plastazote #3 with full length neoprene topcover) work great if the pain doesn't respond within a few weeks of initial care. The worst cases I have seen have required below-knee casting for 4-6weeks, but this is unusual.

If you know your foot anatomy, and you know how to properly examine the foot, you should be able to make this diagnosis with 10 seconds of examining the child.

 

Thanks Kevin.

What were the results after the casting treatment? Absolute reduction in pain levels? Or relative reduction?

 

Thanks Kevin.

What were the results after the casting treatment? Absolute reduction in pain levels? Or relative reduction?
And also the assumption of posterior-plantar heel pain as Sever's places other diagnoses out of the box - Ie Plantar faciittis, facial tear, baxter's. Some cases of sever's manifest different to others, this is what experience reveals?

 

Casting works great...as long as you don't take them out of the cast too early....use pain and tenderness as your guide....children heal like gang-busters, as long as the injury-causing stresses are completely removed from the injured calcaneal apophysis.

Like I said, if you know your anatomy, and how to examine for Sever's, this condition will not be confused with plantar fasciitis, Baxter's neuritis or a plantar fascia tear in an active 8-12 year old. Sever's disease tenderness is specific to the medial and lateral margins of the posterior calcaneus at the junction between the calcaneal apophysis and the calcaneal body. Sometimes the tenderness extends into the plantar aspect of the posterior heel at the most plantar aspect of the apophysis, but I have never seen it involve the plantar aspect of the medial calcaneal tubercle. I have never seen a Baxter's neuritis in anyone under 20 years old, I have never seen a plantar fascial tear in anyone under 25 years old and if someone who is in their preteens and teenage years has plantar fasciitis, their pain will nearly always be in the midportion of the plantar fascia, not at its insertion into the medial calcaneal tubercle. If I sound overconfident, I suppose after you have treated about 500 cases of Sever's disease over a 27 year period, you will be pretty confident also.

 

Experience speaks for itself and as we know is a part of the trilogy that makes up evidence based practice, your experience is greatly appreciated. What are your thoughts then on casting every case of Severs to reduce the 'stresses placed on the calcaneus'? If it's going to give better results than stretching and heel-lifts and orthotic therapy in a shorter time frame with the inconvenience being, being in a plaster cast for 4 weeks? Ie- Would you propose that the benefit and healing time associated with plaster casting rather than physical therapy warrants its use more?

Shalom.