Posterior calcaneal apophysitis is an inflammatory condition that affects the heel bone (calcaneus). It happens frequently in young athletes between the ages of 10 and 13, causing pain in one or both heels when walking. Tenderness and swelling may also be present. Calcaneal apophysitis is actually an injury, not a disease. Children outgrow it with time. In the meantime, symptoms usually get better with rest, pain medication, and proper footwear. This typically requires limiting exercise activity until your child can enjoy the activity without discomfort or significant pain afterward. In some cases, rest from activity is required for several months, followed by a strength conditioning program.
Pathophysiology
- General
- Seen in skeletally immature athletes
- Traction at the Achilles Tendon insertion site correcting with the secondary ossification center
- Occurs with growth spurts, increased activity, or repetitive running and jumping
- Presents as heel pain secondary to overuse
- Resolves with skeletal maturation and closure of apophysis
Causes
- Repetitive strain and microtrauma
- Caused by force of the Achilles tendon which inserts at secondary ossification center
- Results in irritation and potential partial avulsion of the calcaneal apophysis
- Sports
- Running and jumping sports
- Basketball
- Soccer
- Gymnastics
- Extrinsic
- Long or year-round activities
- Poorly fitting or worn-out footwear
- Poor training mechanics
- Intrinsic
- Poor heel cord flexibility
- pes cavus
- pes planus
- genu varum
- forefoot varus
Differential Diagnosis
- Fractures & Dislocations
- Distal Tibia Fracture
- Distal Fibular Fracture
- Talus Fracture
- Calcaneus Fracture
- Subtalar Dislocation
- Ankle Fracture (& Dislocation)
- Peroneal Subluxation
- Muscle and Tendon Injuries
- Peroneal Tendon Injuries
- Achilles Tendonitis
- Achilles Tendon Rupture
- Posterior Tibial Tendon Dysfunction
- Flexor Hallucis Longus Tendinopathy
- Ligament Injuries
- Lateral Ankle Sprain
- Medial Ankle Sprain
- Syndesmotic Sprain
- Chronic Ankle Instability
- Intersection Syndrome Foot
- Bursopathies
- Retrocalcaneal Bursitis
- Nerve Injuries
- Peroneal Nerve Injury
- Tarsal Tunnel Syndrome
- Arthropathies
- Osteoarthritis of the Ankle
- Osteochondral Defect Talus
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin’s Disease)
- Calcaneal Apophysitis (Sever’s Disease)
- Other
- Haglunds Deformity
- Posterior Ankle Impingement Syndrome
- Sinus Tarsi Syndrome
Diagnosis
- History
- Children are typically 8 to 14 years old
- Pain over the calcaneal apophysis/calcaneal insertion of Achilles tendon
- Pain with activity or impact, worse on hard surfaces, wearing cleats
- Resolution of pain with rest
- Limping may be present
- Physical Exam: Physical Exam Ankle
- May have erythema, swelling, warmth
- Tender over achilles tendon insertion
- Pain with passive ankle dorsiflexion
- Tight Achilles tendon and calf muscles
- Pes planus or pronated forefoot may be present
- Special Tests
- Squeeze Test: Pain over the posterior calcaneus with compression)
- Sever Sign: Increased pain at calcaneus with standing on tiptoes
- Clinical diagnosis and imaging is not routinely required
Radiographs
- Standard Radiographs Ankle or Standard Radiographs Foot
- Typically normal, especially early in the disease process
- Rule out other pathology including fractures, osteomyelitis, bone cysts
- Potential findings
- Sclerosis may be present
- Fragmentation is frequently present
MRI
- Findings
- Localize inflammation to the apophysis
- Evaluate for other pathologies stress fracture, lytic lesions, osteomyelitis
Treatment
- Indications
- All patients
- Activity modification/Rest
- Discontinue offending activity
- Physical Therapy
- Achilles tendon stretches, hamstring stretches
- Strengthening of dorsiflexion
- Heel pads/cups
- Insertion can offload some tension on Achilles
- Immobilization in severe cases
- Either Tall Walking Boot or Tall Walking Cast
- May require nonweight bearing status
- Other
- Ice
- NSAIDS
- Establish proper footwear
- Prevention
- Maintain calf flexibility and ankle dorsiflexion
- Limit the use of cleats or time on hard surfaces
Operative
- Indications
- No role for operative treatment
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