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Why is my son suffering from heel pain?

Friday, 13 June 2008
Answered by: Dr. Mathew Varghese
Consultant Orthopaedic Surgeon and Director,
St. Stephens Hospital,
New Delhi
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Q. My son is around 7 years old and is suffering from heel pain in the left foot near the ankle joint for the past six months. The pain is not exactly on the heel but just above the heel at the ankle joint. There is a small point just above the heel, which gives pain on pressing it. I consulted an orthopaedic surgeon who prescribed Voltarin and physiotherapy. I also consulted a podiatrist who said that my son had flat feet and prescribed insoles for shoes, which he is wearing for the past two months. The pain is more after playing and he has started walking with a limp. Actually my son started doing some skipping as an exercise. But he used to skip bare feet on hard surface, which probably caused the pain to develop. His left foot is rolling inside more than his right foot and as per the podiatrist this is not allowing his heel to repair. But he has been wearing the insoles for two months and the pain is still there. What are the treatment options available for my son?

A.  I would look for the growth plate of the heel bone as this can have a problem called Osteochondrosis, which is usually self-limiting and needs only restriction in jumping. Usually this is seen in the age group of 10-14 years but may appear in a younger child Flat foot per se does not cause heel pain it usually causes pain above the heel on the inner or outer side of the foot just below the ankle. Unfortunately you have not mentioned whether the pain is in the inner side or the outer side of the heel. You only mentioned above the heel at the ankle joint. Anyway, I will take you through some of the common causes of foot pain in children. Flat foot: Since you have mentioned your son has flat foot I will start with painful flat foot. Painful flat foot is less common however, if it occurs it is usually in an older child. The pain specifically may be on the outer side of the heel. Some used to call it peroneal Spastic Flat Foot. In such children it is difficult to turn the heel inwards or outwards. I don’t think your son has that. Occasionally, the heel bones may be partially fused causing abnormal stress and pain. Some of these could be painful and present in a younger child. Usually they out grow this pain and simple analgesics may be all that are required. Here also the heel movements may be restricted. It is difficult to rule this out in your child without examining him. Osteochondroses: these are conditions in children affecting the growth plates of bones, especially where muscles are attached. The heel bone growth plate when affected is known as Severs disease. Usually around the age of 10 but may occur in a younger child. Again self-limiting, restrict jumping, give anti-inflammatory medicines and at times giving a heel raise relaxes the heel cord and reduces the pain. The site of pain that you have described does not seem to be that of Severs disease. Achilles tendonitis: A condition where the heel cord gets painful because of inflammation there. The pain is specifically at the back of an ankle and on pressing the heel cord it is very painful responds well to anti-inflammatory and at times giving a heel raise. I don’t think your son has this. Arthritic conditions like Juvenile Rheumatoid Arthritis (JRA) may cause pain in the region of the heel. However, usually there is evidence of involvement of other joints with features suggestive of JRA. I don’t think your son has this. Accessory navicular: Some children have an extra bone on the inner side of the foot a little in front and below the ankle. This bone is the site of attachment of a muscle and number of these children has flat feet. These children, usually older than 10, have pain at the site of the extra bone. Most of them grow out of this pain. An occasional one may need surgery. Your son is a little too young for this. I am sure you are probably a little too confused now but the message I wanted to give you was there are several conditions that can present with pain in the foot. Careful examination and a good history are essential for arriving at a right diagnosis. Treatment in most cases is conservative and usually no surgery is required.

A.  I would look for the growth plate of the heel bone as this can have a problem called Osteochondrosis, which is usually self-limiting and needs only restriction in jumping. Usually this is seen in the age group of 10-14 years but may appear in a younger child Flat foot per se does not cause heel pain it usually causes pain above the heel on the inner or outer side of the foot just below the ankle. Unfortunately you have not mentioned whether the pain is in the inner side or the outer side of the heel. You only mentioned above the heel at the ankle joint. Anyway, I will take you through some of the common causes of foot pain in children. Flat foot: Since you have mentioned your son has flat foot I will start with painful flat foot. Painful flat foot is less common however, if it occurs it is usually in an older child. The pain specifically may be on the outer side of the heel. Some used to call it peroneal Spastic Flat Foot. In such children it is difficult to turn the heel inwards or outwards. I don’t think your son has that. Occasionally, the heel bones may be partially fused causing abnormal stress and pain. Some of these could be painful and present in a younger child. Usually they out grow this pain and simple analgesics may be all that are required. Here also the heel movements may be restricted. It is difficult to rule this out in your child without examining him. Osteochondroses: these are conditions in children affecting the growth plates of bones, especially where muscles are attached. The heel bone growth plate when affected is known as Severs disease. Usually around the age of 10 but may occur in a younger child. Again self-limiting, restrict jumping, give anti-inflammatory medicines and at times giving a heel raise relaxes the heel cord and reduces the pain. The site of pain that you have described does not seem to be that of Severs disease. Achilles tendonitis: A condition where the heel cord gets painful because of inflammation there. The pain is specifically at the back of an ankle and on pressing the heel cord it is very painful responds well to anti-inflammatory and at times giving a heel raise. I don’t think your son has this. Arthritic conditions like Juvenile Rheumatoid Arthritis (JRA) may cause pain in the region of the heel. However, usually there is evidence of involvement of other joints with features suggestive of JRA. I don’t think your son has this. Accessory navicular: Some children have an extra bone on the inner side of the foot a little in front and below the ankle. This bone is the site of attachment of a muscle and number of these children has flat feet. These children, usually older than 10, have pain at the site of the extra bone. Most of them grow out of this pain. An occasional one may need surgery. Your son is a little too young for this. I am sure you are probably a little too confused now but the message I wanted to give you was there are several conditions that can present with pain in the foot. Careful examination and a good history are essential for arriving at a right diagnosis. Treatment in most cases is conservative and usually no surgery is required.

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