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Hi.

Another month, another posting from me about an atypical heel pain presentation.

12-year-old girl. Treated successfully for some 1st MtP joint pain over a year ago with some EVA orthotics.

Returned 2 weeks ago c/o moderate heel pain and pain distal plantar forefoot. Orthotics now too small, as were shoes. No recent injury/trauma reported.

Plantar forefoot discomfort determined to be caused by metatarsal dome support on orthotic. Heel painful when squeezed. Very mobile rearfoot & 1st Mtp joint (Jack's test). Non-weightbearing STJ axis medially deviated. Low supination resistance however (weightbearing). Tinels signs negative medial & lateral calcaneal areas. I took the old orthotics away, she wasn't wearing them anyway by this point.

I assumed Severs disease. I gave footwear advice, issued some 6mm eva heel lifts and suggested she avoid high impact activity & we'd look at gentle stretches.

Mum phoned 4 days later in distress. Pain rapidly worsened by the evening of the following day after seeing me. Girl in tears. Got her back into my office 1 week after 1st visit. She arrived with crutches (having been to A&E). Still in pain. Left foot cold & clammy (wasn't previous week). Pulses all palpable. Pain on palpation medially & laterally anywhere from calcaneus distally to navicular/cuboid region. Inversion & eversion strength low. Patient using parecetamol to control pain, Ibuprofen seems unhelpful on its own.

I considered (amongst other things) Complex Regional Pain syndrome, having seen a young girl a few years ago with a similarly cold/clammy foot. However repeated palpation/percussion on calcaneus did not make the pain any worse than at first palpation.

I repeated advice re: rest, encouraged use of heel lifts in all footwear & advised her to avoid barefoot walking. Sent for U/S & plain x-ray.

X-ray shows normal epiphyses, normal everything. U/S still awaiting report almost a week later (I suspect this is giving the radiologist some headaches too, as they normally report within 2-3 days).

Any ideas?