Calcaneal (heel bone)
Apophysis (growth plate)
-itis (inflammation)

Calcaneal apophysitis is the most common cause of heel pain in children, adolescents and teenagers.

It occurs when there is inflammation of the growth plate (apophysis) at the back of the heel bone (calcaneus), where the strong Achilles tendon attaches. The growth plate can be seen on an X-ray. The growth plate of the heel usually closes at around the age of 16 years.

What are the symptoms?

Children generally complain of heel pain at the back or bottom of the heel.The pain is usually made worse by PE and sports, especially running and jumping activities. Rest often makes it feel better, but pain may return when standing up again. It can affect one or both heels.

Squeezing the sides of the heel bone is often painful. In more severe cases, the child may limp. It is very common for symptoms to be better and worse at different times, often continuing on and off for months or sometimes years.

What are the causes?

Nearly all children with calcaneal apophysitis have tight calf muscles or hamstrings. The Achilles tendon is very strong and attaches directly to this part of the bone. If the muscle is tight, it pulls on the growth plate with considerable force during every step.

When you grow, the frame of your body (the skeleton) gets bigger and stretches all the muscles with it. If you have a large growth spurt, the muscles may struggle to keep up completely and become tight. This places more stress on the heel bone. Overuse is common in children who take part in many activities and have insufficient rest.

For some children, shoes with poor heel padding or arch support, or participation in sports on hard surfaces, can contribute to symptoms.

The condition is also more common in children who are heavier.

How long will it last?

Pain may last for weeks or months and may return if your child goes back to activities too soon or experiences a significant growth spurt.

The treatment remains the same and will usually help symptoms settle more quickly than if no treatment is provided.

What are the long-term consequences?

This condition is self-limiting and will usually resolve once the two areas of bone growth join together, at around the age of 16 years.

Treatment helps symptoms settle more quickly and allows children to return to full activity with less discomfort. In a small number of cases, treatment is not successful and activity levels may need to be restricted until the growth areas join.

There are no known long-term complications associated with this condition.

How is it treated?

Stretching

Stretching is the cornerstone of treatment.

The first week may be uncomfortable. If stretching causes considerable pain, begin stretching after one week of using the heel cushion and Ibuprofen.

Stretches must be completed five days each week, five times per leg per day, and performed using the correct technique to be effective.

Good results and symptom resolution can often be seen within four to six weeks if the advice is followed. Severe cases may take a little longer.

Cushioning

Heel pad

A heel pad can be used for short-term comfort but should only be worn for a maximum of three weeks. Wearing it for longer may actually make the problem worse.

Rest

Do not do anything unnecessary that aggravates your symptoms, but do not stop all activities.

If symptoms are severe, you may need complete rest from activities such as football or rugby to allow the condition to improve more quickly.

Before returning to sport, you should be able to:

• jog without pain
• sprint without pain
• hop on the affected foot without pain.

Other forms of treatment may include strapping or, in severe cases, casting. Foot orthotics may be used if pain continues after the muscle tightness has been addressed.

Things you can do at home

• wear supportive footwear with cushioned soles for sport. School shoes may also improve comfort. Some children may need to wear trainers to school until symptoms improve. Avoid going barefoot
• use ice after your activities have finished for the day, for example after school or sport. Apply for 10 minutes, remove for 10 minutes and repeat as required
• anti-inflammatory medication, such as Ibuprofen, may help. Follow the instructions on the packet. If you are taking other medication, check with your GP or pharmacist first.

Stretches

You will know you are doing the stretches correctly when you feel a good, strong pull in the muscle. There may be some discomfort initially, but there should be no tears in the eyes.

If possible, try completing some stretches before school as a good start to the day. This should only take five to 10 minutes in total.

• hold the position for 30 to 60 seconds
• complete five stretches per leg per day
• complete the programme five days each week as a minimum.

Hamstring stretch

1. Stand facing a bed, chair or sofa and use your hands for support.
2. Put your heel on the bed or chair with your knee bent and your chin on your knee.
3. Gently straighten your knee until you feel a strong pull in the muscle.

Hold: 30 to 60 seconds on each side, five stretches per leg per day, five days each week.

Calf stretch

1. Stand with only the ball of your foot on the edge of a bottom step.
2. Keep your feet pointing straight ahead and your body upright.
3. Gently drop your heel until you feel a strong pull at the back of the leg.
4. Hold on to a banister for balance, but do not bend forwards.

Hold: 30 to 60 seconds, five stretches per day, five days each week.