An 8-year-old boy is brought to the office for evaluation of heel pain. The patient has had increasing pain in the back of his heels for the past 2 months during basketball season. The pain was tolerable until a recent 3-day basketball tournament, which exacerbated his heel pain. He has no pain in other joints and does not recall a specific injury. The patient has no chronic medical conditions and takes no daily medications. Temperature is 36.7 C (98 F). He is at the 98th percentile for height and the 55th percentile for weight. The patient has a normal gait but is unable to stand directly on his heels without pain. Bilateral heels have mild swelling, and the bases of both are tender to palpation. Dorsiflexion of the ankle elicits pain. The Achilles tendon is nontender. Which of the following is the most likely cause of this patient's heel pain?

Question

An 8-year-old boy is brought to the office for evaluation of heel pain.  The patient has had increasing pain in the back of his heels for the past 2 months during basketball season.  The pain was tolerable until a recent 3-day basketball tournament, which exacerbated his heel pain.  He has no pain in other joints and does not recall a specific injury.  The patient has no chronic medical conditions and takes no daily medications.  Temperature is 36.7 C (98 F).  He is at the 98th percentile for height and the 55th percentile for weight.  The patient has a normal gait but is unable to stand directly on his heels without pain.  Bilateral heels have mild swelling, and the bases of both are tender to palpation.  Dorsiflexion of the ankle elicits pain.  The Achilles tendon is nontender.  Which of the following is the most likely cause of this patient's heel pain?

Quizplus · Accepted Answer

11ec25c8_d60b_d82e_bc81_713f60992196_MD0003_00 Heel pain in an active boy is most commonly calcaneal apophysitis (Sever disease), an overuse injury caused by repetitive microtrauma to the calcaneal apophysis (heel growth plate). The condition is typically seen in athletic children age 8-12 who participate in running or jumping sports (eg, basketball) because the apophysis is most susceptible to stress during periods of rapid growth. Presentation involves chronic and often bilateral heel pain that is worse with activity, particularly when wearing shoes without heel support (eg, flip flops, cleats). calcaneal apophysis Diagnostic findings include tenderness with squeezing the heel (calcaneal compression test) and on palpation at the base of the heel over the apophysis. Heel swelling can occur with severe inflammation. In addition, limited ankle dorsiflexion may be present due to an associated tight Achilles tendon and decreased gastrocnemius/soleus flexibility. Treatment is generally supportive with stretching, ice, nonsteroidal anti-inflammatory drugs, and a heel cup insert for cushioning. Symptoms typically improve within a couple of months. (Choice A) Pain associated with Achilles tendinopathy is exacerbated by running and jumping. However, tenderness is over the Achilles tendon (posterior ankle), not the heel. Achilles tendon (Choice C) Enthesitis-related juvenile idiopathic arthritis can present with tenderness and swelling at the insertion point of the Achilles tendon into the calcaneus. However, arthritis (ie, joint pain, swelling, stiffness) of the large joints of the lower extremities would also be expected and is not seen here. (Choice D) Plantar fasciitis presents with pain on the plantar surface of the foot and is most commonly unilateral rather than bilateral. Pain is worst on first stepping out of bed and improves throughout the day. (Choice E) Tarsal tunnel syndrome (due to compression of the posterior tibial nerve) is characterized by pain, numbness, and tingling along the sole of the foot and may extend up to the ankle. In contrast, this patient has localized heel pain without neuropathy. Educational objective: Calcaneal apophysitis is a common cause of heel pain in children who play running or jumping sports. Tenderness at the base of the heel and with calcaneal compression are diagnostic findings. Treatment is supportive. References: Sever's disease (calcaneal apophysitis). (http://www.ncbi.nlm.nih.gov/pubmed/30702528) Heel pain: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/29365222)

An 8-Year-Old Boy Is Brought to the Office for Evaluation