Calcaneal Apophysitis

KIDS INJURIES:    HEEL PAIN

That painful growth injury that makes your child limp on and off the field.  

with Doug James – intraining Running Injury Clinic Physiotherapist & Podiatrist

READ Doug’s article below and download the “ACTION PLAN for Heel Pain” at the bottom to give you and your child a quick guide to help you tackle Heel Pain in kids.  

 

Calcaneal Apophysitis  (formerly known as “Sever’s Disease”)

Calcaneal Apophysitis is one of the most common injuries in early adolescents, though its name is probably unfamiliar to most who would refer to it as “Sever’s Disease”, or more simply “Sever’s”. It is pain felt on the back of the heel bone (calcaneus) around the base of the Achilles tendon in some young people sometime between the age of 7-15 years old [1-5] (the age ranges vary by source but usually falls within 1-2 years of the upper and lower limits). This injury was first identified in 1912 by Dr James Sever, after whom the injury was named[2].

What’s in a name?

While the term “Sever’s Disease” is commonly used today, it is falling out of favour with the medical world. In the past, a medical condition or disease would often be named after the person that studied and identified it. Injury names become increasingly difficult to pronounce when a team of people lay claim to the identification of a condition such as the wordy “Sinding-Larsen-Johansson Syndrome” (a knee pain condition in teenagers), or Klippel–Trénaunay–Weber Syndrome (a blood vessel disorder).

The favoured and current approach is to refer to these “diseases” with a more accurate pathophysiology (problematic process) title so as to better describe the “where and what” of the condition. This move also aims to replace using inaccurate and vague terms such as “syndrome” and “disease” as these names can carry a certain stigma.

So, what is a Calcaneal Apophysitis?

The individual components within the name “Calcaneal Apophysitis” gives a clue as to its nature and location. The Calcaneus is the heel bone. An Apophysis is a bone protuberance or small lump formed on the bone where tendons or ligaments attach, in this case, it is on the back part of the bone where the Achilles tendon attaches. Lastly, the term “-itis” refers to an irritation or inflammation of an attachment site on the heel bone. Put together, these terms describe irritation of the back of the heel bone.  

How does it develop?

There are a few theories about the factors that lead to how and why Calcaneal Apophysitis develops and what the actual source of pain is. One theory is that the Apophysis becomes painful from the Achilles tendon applying repeated or continuous tension to it [5].

Another thought is that the underlying Calcaneus bone (not simply the apophysis) that may be the source of pain. The human skeleton grows primarily from ossification centres. These are the foundations from which bones lengthen and expand making us taller (and wider). The calcaneus has two ossification centres that are located in the middle and rear of the bone, which eventually disappears once the bone has finished growing – usually in the early teenage years.  The rear ossification centre is thought to become painful as it undergoes stress from tension. Clinically, it’s not uncommon to observe tenderness in the lower part of the Achilles tendon as a standalone presentation, or along with the bony heel pain, again possibly due to tension, or possibly trauma. In more severe cases the growth plate can become fragmented (see image 1).

What is the source of the tension?

Calcaneal Apophysitis is often observed in young people that have had a recent growth spurt (but not always). When the shin bones grow (resulting in increased overall height), the muscles and tendons need time to elongate to the optimum length for the newly lengthened legs. In the weeks (and sometimes months) following a growth spurt, adolescents may complain of calf muscle tightness due to the relative shortness of their calf muscles. This muscle tightness can exert a constant strain on the Achilles tendon and the Calcaneal Apophysis which serves as its anchor point and may irritate the Calcaneal Ossification Centre [5].

The Achilles tendon is also subjected to increased tension in flat-soled, and low heel drop shoes. Adolescents with heel pain should be encouraged to avoid walking around in flat shoes, thongs, or bare feet. Calcaneal Apophysitis is fairly common in active young people [1-5]– notably those playing one of the football codes. Many football boots have a low heel drop (minimal height difference between heel and forefoot) which increases pressure on the calf muscle, Achilles tendon and heel. Playing football involves bursts of sprinting which is another activity known to irritate the injury.

Management of the injury

Just as there is little consensus as to the exact nature of the injury, there is no agreement on a universal fix. This may be due to the fact that there are a number of different contributing factors in each individual presentation. As such, each case needs to be assessed and managed uniquely. The most common theme in management strategies is finding a balance of rest and sport/running within an acceptable level of discomfort, as rest alone doesn’t lead to faster improvement [5]. In cases where pain levels are severe, abstaining from any pain provoking activity becomes necessary, though this is thankfully usually rare.

Footwear factors can play a major role in the successful management of the injury, and being able to modify aspects such a heel drop by using firm heel lifts, or cushioned heel cups can be beneficial. Research has also examined whether orthotics play a role in managing Calcaneal Apophysitis though the results are inconclusive [2] (possibly due to the limitations of research that requires a standardised orthotic be used in all patients). Addressing muscle tightness issues when present is also important for managing pain levels, and expediting recovery time. This can take the form of calf muscle massage, ankle mobilisation, and where appropriate – a targeted stretching program.

How long does the injury last?

It can be difficult to predict how long Calcaneal Apophysitis will last. In a majority of cases, there is a resolution of symptoms soon after the sporting season finishes. In a smaller number of cases, the pain can persist for up to a year, or longer in an unlucky few.

Imaging such as X-rays are not always necessary, but in more severe cases can be helpful to assess any derangement of the Calcaneal growth plate which is often associated with greater pain and longer recovery times.

When to seek treatment?

It is useful to have an assessment when heel pain symptoms first present (which is often in the first few weeks of a new sports season or following a significant growth spurt). Learning ways to manage the pain is crucial to helping settle the symptoms and improve quality of life, while hopefully allowing a continuation of physical activity. An assessment of the patient’s footwear, walking and running biomechanics, and muscle testing can help to develop a personalised treatment and successful treatment approach.

For a thorough assessment of adolescent heel pain, contact the intraining running injury clinic for an appointment to see a Podiatrist or Physiotherapist who can assess the injury and design a custom management plan.

Doug James – intraining Running Injury Clinic Physiotherapist & Podiatrist

References

  1. Uvelli, K. O., Neher, J. O., & Safranek, S. (2017). Treatment for Calcaneal Apophysitis. American Family Physician, 96(2), 126–127.
  2. James, A. M. M., Williams, C. M. P., & Haines, T. P. (2013). “Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (sever’s disease): A systematic review” Journal of Foot and Ankle Research, 6(1), 16. https://doi.org/10.1186/1757-1146-6-16
  3. James, A., Williams, C., & Haines, T. (2013). Contributing factors in children who present with calcaneal apophysitis. Journal of Science and Medicine in Sport, 16, e26–e26. https://doi.org/10.1016/j.jsams.2013.10.064 
  4. James, A. M., Williams, C. M., Luscombe, M., Hunter, R., & Haines, T. P. (2015). Factors Associated with Pain Severity in Children with Calcaneal Apophysitis (Sever Disease). The Journal of Pediatrics, 167(2), 455–459. https://doi.org/10.1016/j.jpeds.2015.04.053
  5. Williams, C. (2016). Wait and see, heel raise and eccentric exercise may be equally effective treatments for children with calcaneal apophysitis [commentary]. Journal of Physiotherapy, 62(2), 112–112. https://doi.org/10.1016/j.jphys.2015.12.003

Image 1: Sourced on 07.10.20 from https://radiopaedia.org/cases/sever-disease-6

ACTION PLAN for HEEL PAIN

DOWNLOAD This Action Plan to help you and your child reduce the risk and severity of heel pain.

These simple strategies may save you a lot of worries.

We all care about your kids and want them to love their sport for life.  

 

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Running at the Mouth

Running at the Mouth

By Margot Manning

4 Tips to get your Kids out of bed for a Run

Raising kids is like painting a picture.  You need to be creative.

It takes time. When a mistake is made you need to retry but with a different technique…   and there are so many moments along the way when you can admire their progress.

Now, I am NOT an artist like my daughter or an expert in raising kids.  I just appreciate the process of the artist and similarly enjoy creating running experiences with the hope that kids eventually love running and will value it as a lifelong activity.   

So, here’s four of my favourites tips to help them embrace the love of running.  

Tip #1  Play to their highest desire (without blatant bribery)

Speed and stamina….   Soccer players and netballers and most kids playing sport want to be faster and have more stamina in their games. Running does that and after a few weeks, both you and your child will realise how much better they are performing on the field.  

Food…   Profiteroles, pancakes, hot chocolate and Slurpee surprises after the run are excellent ‘bonuses’ which can be as regularly or irregularly as you like.  Spontaneous food treats are one of my thank-you’s to them for running with me and a great way to keep them talking.

Jacqui Lynagh, mum of two children said ” Finding ‘your’ purpose is always a good thing to talk about.  My son has his – he wants to be able to run fast in the soccer game right until the end.”  

Tip #2  Run in the rain

Running in the rain is incredibly fun.  The harder the downpour the better because the puddles are larger, the tree leaf droplets denser and the challenge to stay ‘dry’ harder.   Running in the rain has always been one of our favourite runs together and works nearly every time to get my kids out the door or the kids excited at the training groups.  The downside happens when they use their puddle splashing skills in public races… oops!

Tip #3 Fun running

Immerse your children into fun runs.  There is less pressure, they can ‘disappear’ into the crowd if they want and will get cheered by the older run folk…  aka… the parents. Even more amazing is watching them become confident as they mix and communicate with other runners of all ages and all ability levels.

Tip #4 Don’t give up… because they grow up

Your children will turn thirTEEN and realise that post-run pancakes are not really as good as the comfort of their bed.    

Don’t despair because they will see you running and enjoying your time out.  Since they had already experienced some of this they will reconnect with the running community and you know that here they will always be cheered and supported.

intraining Coach Tracy Baker recently posted “It’s a miracle” at seeing her two kids begin their running journey.   “You know your kids are proud of your running achievements when they stop saying you’re crazy because they’ve finally decided to buy their first pair of running shoes at 27 & 29.”

There are so many different ways to create running experiences for our kids. These are just a few of mine. I’d love to know what ones you have created or the conversations you have created.  Email me here or share your comments on our Facebook page.

Keep reading to see what other parents and kids have to say…

This is what Julie Whitehead shared after celebrating a joint 50th parkrun with her daughter, Nicola…  “My tip would be to go at their pace when they want you to be with them, leave them be when they want to go it alone and celebrate the very fact of being out there – that is the big achievement. ????????

intraining Coach and club president, Paul Broad’s daughter Isla said ” When I grow up, daddy, I want to run a marathon and you be on the sideline yelling “go intraining”  (Aged 3)

And just for the record…. we all know that even when they are there to run, teens can sleep anywhere!!  You have got to love them!!!

Margot and her husband Steve own intraining Running Centre and have been coaching kids for more than 30 years.   They have created intraining to help people of all ages and abilities to run by developing coaching groups and programs, the intraining running shop, their podiatry & physiotherapy running injury clinic, the intraining Running & Triathlon Club, Twilight Run Fun Runs and an awesome team of coaches.  They love running and want to share this with everyone.  

Kids racing through childhood

Kids racing through childhood

by Margot Manning, intraining podiatrist and running coach

As a parent it can sometimes be hard to watch primary school races knowing that your child can be up against some kids who have much higher training loads or who are so much ‘bigger’.  

There are so many factors at play… different phases of physical & emotional maturity between children of the same age, and on different days of the week for the same child.  Most of the time, it is a game of patience, waiting, and nurturing until the child is almost at high school age.  There is also an element of keeping your fingers crossed in the hope that the plan of waiting pays off. 

The moment does come however, when there is a transformation and ‘your boy races as a man’.  The change, of course has occurred over some time, however, it can seem that the emotional and physical maturity just happens overnight.  Gone are the anxious warm up discussions, moments of self-doubt, and frequent checks on competitors.  Gone also is the wiry, knobbly kneed child.   Standing at the start line is a noticeably more robust & stronger looking student with the composure that says: “Bring it on, I’m ready to race.” 

And the race does happen… Spectacularly.  There is control in those frantic moments after the gun fires; contact maintained with the leading pack; and a sprint finish that causes a reverberating cheer from the stands.   Success…  and a huge boost in your child’s confidence.  Suddenly everything seems to have fallen in place and you have a new child.  

This ‘morph’ is a reminder as a coach, and parent, that children’s successes will come with maturity.  The age at which this happens is unknown and will be different for each child.  The key to succeeding is to provide running experiences where they can experiment and learn what it is like to run with both wins and losses and with the ultimate goal to eventually love running. 

The new Kids Love Running program is a place where you as a parent and your child can discover running.  It’s where you will learn what type of runner your child is, how to help your child establish the habit of running.  It’s a place where your child will learn strategies, tips and race tactics, and ultimately where they might find that love of running. 

P.S. The original article was written years ago after one of our junior intraining runners had a breakthrough.

It was an incredibly exciting moment because after years of trying to qualify for a regional team, the boy ran the race of his life to place.  

Luckily, as a coach, I see the ‘morph’ occur with so many of our boys and girls from the intraining running groups. 

Heel pain and kids

Margot image
Article by Margot Manning (podiatrist, kids coach and runner)

Don’t let heel pain stop your kids from running

Heel pain (Sever’s Disease) in children is one of the most common injuries experienced in active kids today. Heel pain occurs because the Achilles tendon vertically attaches to the back of the heel bone (calcaneus) where there is a growth plate, which is active during adolescence.

The growth plate is the area where new bone cells are generated and is present until between the ages of 13-16 when children stop growing, and the bone fuses, to make the completed heel bone. During this time, running, jumping, kicking and rapid changes in direction that children do while playing sport exerts an incredible amount of sheer force and pulling onto the growth plate. This pulling can create soreness which can be quite debilitating for children and interfere with their ability to play without pain.

Early detection and management

Early detection of heel pain and being proactive can reduce the severity of heel pain and help your kids get back to being kids and enjoying being active. Below are three of the most successful management strategies for treating heel pain in kids.

The 3 most successful management strategies for Sever’s Disease:

  1. Understanding how your child runs to eliminate biomechanical concerns.
  2. Checking footwear and modifying if required during pain.
  3. Creating a management plan to help both you and your child know what to do before and after playing sport.

Have you noticed any of the following with your child?

  • Limping when walking or when active
  • Favouring one leg over the other
  • Adversity to activity due to pain in the heel
  • Complaints or comments about soreness in the heel
Kids training groups
At intraining we offer kids training groups during the week. Find out more by clicking the image.

If you are unsure whether you child has Sever’s Disease, or have noticed any of the above symptoms it is time to take action. Don’t let your kids suffer in pain any more. Our team of podiatrists and physiotherapist at the intraining Running Injury Clinic can help diagnose, assess and provide management strategies to help your child return to activity – pain free.

Make an appointment to see one of our podiatry team today. Often there is minimal out of pocket expense with private health cover claimable on the spot. We recommend you bring all your child’s shoes with you to the appointment so these can each be assessed and possibly modified to help relieve pain.

To make a booking call intraining Running Injury Clinic on 07 3367 3088 or click the button below to make an appointment online.

Make appointment

Children vs adult injuries

I’m Getting Too Old for This!

childrenrunningNot a promising statistic – according to Sports Medicine Australia, up to 70% of runners suffer an injury each year. Age is a known contributor to injury risk, and significantly influences the types of injuries that runners are likely to suffer. Whilst children often seem like invincible energiser bunnies, they too can be sidelined due to injury, particularly if they’re doing high volumes of training.

In general, children will recover more quickly from injuries, and the prolonged recovery time is a common frustration for older runners. However, this does not mean that the injuries children suffer are any less damaging. In fact, if poorly treated, serious childhood injuries can significantly impact their growth and development, and taint their passion for running for months or even years to come.

Efficient and injury-free running relies on a synergy between the muscles, ligaments, tendons and ligaments. Injury commonly targets the weakest link in this chain, which differs for adults compared to children, and is influenced by other factors including running history, body composition, biomechanics and running gait.

Bone growth occurs throughout childhood and adolescence. During development the growth plate is weakened, and thus prone to injury. Children are at higher risk of such injuries for approximately 6-12 months within a 3-4 year window, with susceptibility varying depending on the bone/region in question. Growth plate injuries (Apophysitis) are more common in active children. These growth-related injuries resolve with time, but treatment should be undertaken to reduce pain and manage the injury to ensure it doesn’t cause permanent damage. Common examples of Apophysitis injuries include:

  • Sever’s Disease (Posterior Calcaneus – Achilles Tendon)
  • Osgood-Schlatter Disease (Tibial Tuberosity – Patella Tendon)
  • Sinding-Larsen-Johansson Syndrome (Patella – Patella Tendon)

Activity modification and load management are important when treating Apophysitis injuries. Treatment should also address contributing factors and biomechanical issues to assist in pain and symptom relief. For example, Sever’s can be successfully managed with many strategies including regular icing and the addition of heel lifts to all shoes to reduce strain on the Achilles tendon and posterior heel.

Article by Emily Donker. Podiatrist, coach and runner
Article by Emily Donker.
Podiatrist, coach and runner

The soft tissue structures in children are much more pliable and more resistant to injury. Therefore, muscle and tendon injuries are much less common. Young bones are also more flexible and less brittle, so they too are more resistant to injuries, and stress fractures in particular are unusual injuries for children. Fractures are not uncommon, but in most cases they result from acute trauma. As with adults, unusual injuries such as cancerous tumors and systemic conditions are not out of the question – hence it is always important to seek professional advice.

Be aware that active children are likely to suffer an injury at some point, whether it be due to training or a traumatic event. Even though their pain may be inconsistent, or their symptoms may be different to those experienced by adults, their injuries should not be ignored.

Serious injury can lead be detrimental to their long-term health and well-being, so they should be given the same treatment opportunities as adults to ensure their injuries are diagnosed and managed as efficiently as possible. A good pair of correctly fitted running shoes will certainly help avoid injury – read the article why here.

If your children are experiencing any pain or discomfort whilst running or in their day to day active lifestyles, it is time to make an appointment at intraining Running Injury Clinic to see one of our podiatrists or physiotherapists. If you have private health cover, you are able to claim on the spot with minimal out of pocket expense. Don’t ignore the problem, get it seen to sooner rather than later.

Knee pain in teens

Knee Pain, Teens, & Pre-teens

Knee pain is a common injury affecting one third of adolescents and causing disruption to their sports training & performances. (Rathleff et al, BJSM, 2015) The most common knee injury is Patella Femoral Pain Syndrome (PFPS).  Girls are affected more than boys and adolescent girls are also affected with ACL injuries 2-10 times more than boys.  (Myer, 2013).

Myer’s research paper also suggested that one of the major differences between girls & boys during a landing task was the overactivation of the quadriceps with decreased hip flexor activation in girls.  This led to an increase in rotational forces at the knee, called knee abduction moments.  Knee Abduction moments appear as a movement of the knee inwards or internally rotating over the planted foot.  (see image)  This is clearly visible during landing in volleyball, netball, and basketball.

kneeSports that involve cutting movements such as football and touch increase the force of Knee Abduction Moments (KAM) due to the higher speeds of landing and rotation in a single leg stance. The greater the increase in the KAM, the greater the risk of PFP & ACL injuries.

During maturation, boys had shown to have the opposite muscle activation to girls with an increased hip flexor activation.  This higher activation of hip flexor muscles in the body could potentially balance the quadriceps activation & limit rotational forces at the knee.  Myer also suggested that during maturation phases, girls with increased height and mass are more prone to earlier onset of PFPS.

Based on these findings and on the more widely known understanding of quadriceps involvement, students who are experiencing PFPS need to undertake a quad strength, and neuromuscular exercise plan. Most of these students will respond well to a specific & individualised program designed by a qualified health professional.  They also need to relearn jump landing strategies, cutting movements, and single leg movement patterns for their sport.  Sometimes other interventions such as footwear, and added support such as orthotics may be required if there are more specific anatomical and biomechanical issues.

A recent paper published this year in the British Journal of Sports Medicine found that additional exercise sessions done at school helped increase the recovery time for PFPS in adolescents.  (Rathleff, 2015).  These can be conducted by the sports educator / trainer as part of the warm up routine with the team.  FIFA have thoroughly researched ways to reduce injury risk and have produced an exercise routine called FIFA 11+  that is readily accessible online.

As sports educators, coaches and trainers are usually the first person to recognise injury and or complaints of pain by adolescent sports girls & boys.  It is worth talking to the students, and referring them for further investigation with the view that they will be given an appropriate strength program.  Further helping them at training by including their exercises into the warm up routine is more likely going to keep your players on the field for longer and hopefully performing without pain, or with less pain throughout the season.

Margot_ManningAt intraining, we have a team of health professionals including podiatrists & physiotherapists who are experienced in treating sports related biomechanical injuries. Our clinicians understand the need to help students cope with the high loads of sporting commitments and injuries they experience. If you wish to discuss any concerns regarding injuries please contact us here.

Written by Margot Manning
Podiatrist, Level 2 Athletics Coach, Runner & Owner of intraining Running Centre
intraining Running Injury Clinic

References

1.    Rathleff, M., Roos, E.M., et al. Exercise during school hours when added to patient education improves outcome for 2 years in adolescent patellofmoral pain:  a cluster randomised trial.  Br J Sports Med 2015; 49:406-412
2.    Myer, D., Ford, K., et al.  high knee abduction moments are common risk factors for patellofemoral pain(PFP) and anterior cruciate ligament (ACL) injuries in girls:  IS PFP itself a predictor for subsequent ACL injury?  Br J Sports Med 2015; 49:2 118-122
3.     FIFA 11+