Monday, December 2, 2013

Heel Pain in Children

Heel pain is common in people of all ages, but the cause of heel pain can diiffer dramatically between adults and children. Because of this, treatment for heel pain in children is different than for adults, and generally a foot specialist is needed to accurately diagnose the source of heel pain in a child. This article will discuss the various causes of heel pain in children, and how treatment differs.Heel pain is caused by many different conditions. In adults, heel pain is caused by strain to tissue in the arch called the plantar fascia. The resulting condition is commonly referred to as plantar fasciitis, and mistakenly known as a heel spur (which may or may not be present) Children can get this condition, especially if they have very flat feet, but this is not common. Childhood plantar fasciitis tends to be due to arch fatigue from flat feet, causing chronic arch fatigue after standing for awhile. This in turn strains the plantar fascia after awhile, but not in the same acute way that adults injure their foot. Simple stretching exercises and prescription orthotics shoe inserts tends to relieve this condition in children, while adults require additional medical treatment to resolve the more severe inflammation component they develop.The most common heel pain cause in children is inflammation within a growth plate on the back of the heel bone. The child's pain is usually located on the back or the back bottom of the heel and is present with increased activity like running, or even present with simple standing or walking. This pain typically occurs from the age of 10 until the early teen years, when the growth plate 'closes' and stops growing bone. Certain high impact activities, like running, sprinting, and jumping, can force this condition to develop. In many cases, this inflammation simply develops on its own, without injury. To be accurate, it will generally resolve on its own. However, help is needed to accelerate the process and bring the child back into activity. The condition is called calcaneal apophysitis, and is easily diagnosed by foot specialists, and generally pediatritians as well. X-rays are needed to rule out fracture, which, though rare, is possible. The growth plate can be sensitive to crush injuries of the heel bone, and on occasion an injury in which the Achilles tendon pulls forcefully upward or the back of the heel is struck against an object can produce a fracture at the growth plate. In this case, the foot needs to be immobilized in a cast or walking boot to allow it to heal. For the more typical case of apophysitis, treatment is conservative, and can include some combination of temporary activity/sports cessation, icing, anti-inflammatory medications, Achilles stretching, and heel lifts or cups. Of all of these, activity and sports cessation is the most important, as this condition simply needs time to rest. The other components allow for inflammation reduction and heel support. However, if the heel is not rested, the treatment course will not succeed and the pain will persist for many months. Most children improve back to normal after a month or two of rest. Unfortunately, it is this author's experience that many children and their parents will refuse to rest, citing the need to continue with year round sports like baseball or basketball, even if in pain. They simply expect a more convenient solution. In all likelihood, most children in early adolescence are not yet world class athletes who require sustained training, and a couple of months of rest from sports will not spoil their dreams of athletic stardom. Parents need to keep this in mind when their children develop this condition.Other causes of heel pain in children, beyond traumatic fractures of the heel bone, can include simple skin-based problems like a painful wart, or foreign body that has entered the skin. Children often walk barefoot, at home, in public, and at their friend's homes. This increases the likelihood that the child will step on some object that can cause harm. If that object is a small flake of skin tissue from someone who has a wart, then the virus that caused the wart can potentially infect the barefoot child, and form a wart of its own. This viral infection does not cause the immune system to activate against it, presumably because it is limited to the outer layer of the skin and does not circulate in the blood stream. This allows a favorable environment for the virus to exist in the skin, and this may lead to more warts to form as a result of the action the active virus has on the skin. It is not uncommon for warts to form on the bottom of the heel, which can be painful when weight bearing pressure is applied to the wart. Treatment for this usually involves using mild skin acids to stimulate an immune response, and force the body to destroy the virus. Other treatments include freezing the wart with liquid nitrogen, injecting anti-tumor medications, and using other immune-system modifying topical medications. Surgery is performed for stubborn cases, but rarely results in full immunity from the virus like non-surgical treatments achieve. Therefore, it is not uncommon for a wart to return in a nearby location after surgical removal. Barefoot activity also places children at risk for stepping on small sharp objects that can pierce the skin and sit just under it's surface. These objects include splinters, glass and ceramic fragments, sharp plant material, and metal shavings. When inside the body, the skin will naturally wall off these smaller particles into a scar-like ball of tissue, almost like an oyster forms a pearl around sand. The resulting small capsule can push into skin nerves, and cause pain when pressure is made on the bottom of the foot. Inflammation of the surrounding tissue develops, and sometimes bacteria on the small particles cause a local infection. Treatment involves antibiotics for infections, and usually a minor skin procedure to remove the remaining foreign object and surrounding capsule.Less commonly seen causes of heel pain can include foot symptoms of systemic diseases like juvenile rheumatoid arthritis. There are a group of diseases that involve the immune system attacking tissue in joints and the tissue that connects to bone. These conditions can create chronic heel pain and inflammation deep near the heel bone. Although very uncommon, these conditions need to be assessed and treated by a rheumatologist (joint specialist), especially when they develop in childhood. Treatment of the overall disease tends to help reduce heel and foot symptoms. One final uncommon cause of heel pain can include symptoms associated with tumors of the heel bone, both benign and cancerous. Heel bone masses are very uncommon, and heel bone cancer is even less common. Certain expansive cysts and cartilage masses can develop within the heel bone, causing pain and possibly leading to weakening of the heel bone and fracturing. Treatment generally involves removal of the bone defect and filling in with bone chips. More serious tumors of the heel bone are cancerous, and require immediate and aggressive treatment to save the child's leg and life. To be certain, these tumors are very rare, but need prompt diagnosis and treatment when present.When properly assessed, most childhood heel pain can be easily treated. The usual cause does differ from adult heel pain, and therefore the proper treatment program needs to be employed specific to the cause of the child's heel pain. Ignoring the pain, or assuming it is simply 'growing pains', simply leads to a longer duration of pain, and unnecessary loss of the child's activity.



Dr. Kilberg provides compassionate and complete foot and ankle care to adults and children in the Indianapolis area. He is board certified by the American Board of Podiatric Surgery, and is a member of the American Podiatric Medical Association. He enjoys providing comprehensive foot health information to the online community to help the public better understand their feet. Visit his practice website for more information.

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