Introduction
A child or adolescent with skeletal immaturity has unique conditions in the growth centers of the bones; the growth centers in adults are closed. Foot, ankle, or heel pain is common in children or adolescents who participate in sports. Most heel pain cases involve mild trauma or recurrent stress, poor foot and lower extremity biomechanics, and sports or leisure activities like long-distance running, volleyball, and dance (particularly ballet). The child's skeletal maturity is appropriate for their age. Hence, a comprehensive history, physical examination, and knowledge of the pediatric skeleton are required to evaluate and manage pain.
What Is a Growth Center?
The growth center involves soft tissue or ligament, later replaced by bone cells, which aid bone growth and shape, also called apophyses. These growth centers are commonly found in the elbow, pelvis, heel, and other areas. The apophysis is in the calcaneus, or heel bone, attached to the Achilles tendon. Any traumatic injury to the Achilles tendon around 8 to 12 years of age results in heel pain.
What Are the Biomechanics of the Foot?
The gait (action of walking) cycle is the time interval between two successive occurrence of repetitive events.The gait cycle consists of two phases: the stance phase (part of the foot is in contact with the ground) and the swing phase (the foot is not in contact with the ground and the body weight is borne by the other leg and foot). It is useful for recognizing complex foot movements during walking and running. There are four stages of the gait cycle:
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Contact (Heel-Strike to Foot-Flat): When the foot is lower to the ground, the midfoot and forefoot enter the midstance, generating stress on the Achilles with less impact on the lower extremities.
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Midstance (Foot-Flat to Heel-Off): The cycle progresses from the flat foot to the heel lift, and the body's gravity circulates from behind to over the foot, which provides maximum shock absorption and later turns the foot into a stiff lever.
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Propulsion (Heel-off to Toe-Off): Propulsion is the process of moving from heel lift to toe-off. The body moves forward and supports the foot's supination during heel rise, followed by muscle contraction, while toe-off aids muscle extension to move the body forward.
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Swing (Toe-off to Heel-Strike): The gait cycle concludes with the swing phase. The foot position makes contact during the heel strike, then dorsiflexes to prevent the toes from striking the ground.
What Causes Heel Pain in Children and Adolescents?
An overuse injury is the most common cause of heel pain in children, especially among young athletes aged 7 to 15. The other conditions that cause heel pain are:
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Sever’s Disease: When the heel bone grows, the surrounding muscles and tendons become stretched and inflamed due to this sudden growth spurt. Sever's disease, also known as calcaneal apophysitis, is an overuse injury caused by repetitive movements like running and jumping. This is most likely to occur on one or both sides. The discomfort generally develops gradually and is not connected to a specific injury.
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Symptoms: Generalized pain in the heel that is aggravated by physical activity, mainly running or jogging. The piercing or stinging pain is experienced by squeezing the heel bone.
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Treatment: The treatments are based on the severity of the injury. The most typical treatment for this condition is adequate rest. To aid switching, adding heel cups could be suggested. To assist with comfort during rehabilitation, ankle stretches might also be beneficial. Resuming sports and other forms of exercise may help progressively prevent a recurrence. In the chronic case, the child's gait (the pattern of the foot hitting the ground) is altered to relieve pressure and the pain generated by the growth plate. The complete immobilization of the foot is employed in severe cases for about 2 to 3 weeks with the help of a controlled ankle motion boot.
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Achilles Tendinitis: The Achilles tendon is the thin ligament that connects the calf to the heel. Any overuse injury to the tendon results in inflammation and eventually causes Achilles tendinitis. It is commonly seen in young children and adults who actively participate in sports.
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Symptoms: Generalized heel pain is aggravated by running and other sports activities. Swelling, a creaking sound on movement, muscle weakness, and shooting pain when wearing tight shoes.
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Treatment: The first line of treatment is rest, followed by ice compression therapy and foot elevation, which decrease inflammation by promoting blood flow. Physical therapy, along with a soft cast, is indicated for temporary immobilization. Surgical intervention is completely rare with Achilles tendinitis.
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Heel Fracture: Heel fractures are uncommon in children and adolescents because of growth spurts and the elasticity of the bone. However, children who engage in high-impact sports are more likely to develop foot fractures. Heel fractures are classified into four types:
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Open Fracture: The fracture occurs with a skin rupture, resulting in an open wound.
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Closed Fracture: The fracture of the bone occurs without the skin rupturing
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Displaced Fracture: The fracture disrupts the alignment of the bone.
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Non-displaced Fracture: A fracture that does not disrupt alignment. The fractured end remains intact.
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Symptoms: Predominant pain and swelling, bruising, restricted foot movement. Even standing aggravates the pain.
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Treatment: A walking cast or shoes with a firm sole is recommended to relieve pain and discomfort. The common treatment involving "Buddy" taping involves attaching the broken toe to its neighbor's healthy bone. In contrast, the treatment modalities for an open fracture depend on the severity of the injury, although surgery is rarely indicated with a heel fracture.
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Achilles Tendon Bursitis: Overuse of the ankle by means of walking, leaping, or running, which leads to bursa irritation and inflammation, is the primary cause of Achilles tendon bursitis. It is more likely to occur in kids with abruptly increased physical activity levels.
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Symptoms: Pain in the back of the heel that increases with standing, running, and other physical activity; warmth and redness associated with bursitis result from inflammation.
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Treatment: Rest, ice therapy, compression, and foot elevation promote blood circulation, which aids significant healing. In some cases, the immobilization of the ankle is required for several weeks. In addition, customized heel wedges reduce the stress generated on the heel, and physical therapy improves flexibility and strengthens the muscles around the ankle.
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Conclusion
Foot and ankle pain is common in young athletes. Painful conditions are often age-specific and connected to bone maturity. Understanding congenital anomalies, developmental variation, skeletal maturation, and lower extremity alignment will aid the physician in evaluating and managing heel pain. The return to sports is based on recovery factors often suggested by physicians in sports specialists.
