Heel Pain in Children – Information for Referrers

Heel pain is common and settles with a combination of stretching tight muscles and resting from activities which exacerbate the symptoms, especially jumping sports. The majority of these children do not require referral to orthopaedics as no specific treatment is required. A referral to physiotherapy is usually helpful.

As the pain improves physical activity can be gradually increased as comfort allows. It is not uncommon to get more than one episode of heel pain, and if the symptoms do recur, the same advice applies. As this is a condition of childhood, once growth has completed the symptoms do not usually recur.

Heel pain is very common in children and is sometimes referred to as Severs disease. This is a misleading name, as it is not a disease, but more a side-effect of growth. It commonly affects children going through a growth spurt when the bones grow faster than the soft tissues (muscles, ligaments and tendons). This causes traction on the insertion of the Achilles tendon into the calcaneal apophysis. It is more common in physically active children especially those participating in running and jumping activities.

The average age when this is first detected is 11.5 years. It is more common in boys and in about 60% of patients both feet are affected.

We know that when a growth spurt occurs tightness in the calf muscles and Achilles tendon cause a pull on the heel bone leading to pain. Other symptoms can include an intermittent limp or toe walking, swelling, warmth and even redness at the heel. These can be made worse when active and commonly children complain of pain after sport. The pain will improve as the growth slows down, and eventually disappear completely.

Diagnosis is made through history of symptoms and clinical examination, an X-ray is not needed to confirm the diagnosis.

The treatment for heel pain is a combination of resting from certain activities and physiotherapy to address tight muscles. Treatment options may include:

• Activity Modification - avoiding aggravating activities, especially jumping sports.
• Ice applied to the heel can help with pain and reduce any heat or redness.

Activities which may exacerbate the symptoms include running, jumping and high impact activities. While the pain is present, the child should completely rest from these activities and gradually re-introduce them once the pain has settled. During periods of rapid growth it is likely that the symptoms will flare back up and another period of rest may be required.

Occasionally, the calf muscles and Achilles tendon may tighten up. A physiotherapy referral will provide the child with calf stretches to stretch out these muscles and try and reduce the chances of recurrence in adolescence.

Example Stretches: Perform these for 30 seconds, 3 times each leg, twice a day.

Stand with both hands leaning against the wall.
Bring one foot back behind you keeping your toes level and straight.
Bend the front knee and keep the back leg nice and straight.
The stretch will be felt in the back leg in the calf.
Perform these for 30 seconds, 3 times each leg, twice a day.

Stand on a step.
Stand with only the balls of your feet on the step.
Allowing your heels to drop down below the height of the step.
You will feel the stretch in the back of your calf.
Perform these for 30 seconds, 3 times each leg, twice a day.