This is a common injury seen in our office amongst children, particularly engaged in soccer, football, basketball, and other running and pivoting sports. The calcaneal apophysis is a growth center at the lower back of the heel where the Achilles tendon and plantar fascia ligaments attach. This growth plate (apophysis) injury occurs in children at approximately age 7 and may continue as the foot grows, until the growth plate closes at around age 13 or 14. In this injury, children may complain of pain at the back or bottom of the heel, which may limit them from participating well in sports.
The growth plate gets irritated from the pulling of tight calves and/or gets irritated by excessive teeter-totter motion of the heel as it impacts the ground. This causes strain and irritation to the Achilles and plantar fascia insertions on the heel. We particularly see this in patients who have feet that excessively collapse or roll inward (pronate) plus have tight calves. Once the injury has progressed, pains can also be worse at push-off. Shoes that have minimal support such as cleats or lighter weight running shoes exacerbate the injury. Problems are also more frequent during times of active growth spurt.
Examination includes squeezing of the heel bone. If pain is elicited in a growing child, this is typically diagnosed as calcaneal apophysitis. It is quite common for patients to come to our office having had this problem in the past for several weeks/months. X-rays are taken in our office which sometimes reveal a subtle fracture of the growth plate.
It is of utmost importance for our doctors to perform a biomechanical examination to determine one’s foot type and any excessive motions which may lead to the progression of this painful condition. Competing on soft, bumpy, or soft grassy surfaces (ie: after rainfall) causes excessive motions of the foot further straining the Achilles and plantar fascia insertions upon the growth plate. Once the pain is quelled, the trick is to reduce excessive foot and leg motion while progressively increasing the young athlete back to normal activity levels.
Treatment initially includes reduction in physical activities. Rarely do our patients have to totally stop sports activities. Fracture of the calcaneal growth plate is a more serious condition and may involve a short period of cast or brace immobilization. Once our patients are progressed back into activity, we fabricate flexible temporary orthotic devices to reduce the teeter-totter effect of the heel bone when it contacts the ground. Also by stopping the collapse of the arch, there is less stress to the foot and calcaneal growth plate. We also frequently tape the Achilles or apply a soft cast so patients may continue their activity with less strain to the injured area. We call this “active rest”; the patient continues activities yet the unwanted excessive motion is limited. A heel lift may also be added to the orthotics or shoes to further reduce strain of the plantar fascia and/or Achilles tendon. Patients typically return to our office in 1 week reporting significant reduction in pain. Many patients return once a week for a few weeks for an Achilles/heel taping or soft cast application, which allows them to continue their sports activities without pain.
Gentle stretching may be performed; however, this may exacerbate the injury if performed too early in the recovery process. Ice and anti-inflammatory medications are indicated; however, strong medication may mask the pain during activities and is to be avoided. Should your child or anyone you know be suffering from calcaneal apophysitis, please do not hesitate to contact our office so we may expeditiously and successfully treat this condition.
Written by Richard T. Braver, DPM, FACFAS