By Dr. Don Kirkendall

Dr. Don Kirkendall

Heel pain. This is a topic for what some might think is a narrow audience. It’s about something an early adolescent player might complain about. Mostly boys, but can happen in girls, who are getting started with puberty. Players between 9 and 12 years of age.

Your player might complain about, or show some evidence of, a painful heel that gets more painful with walking, running or jumping. If the pain gets worse, the player may limp or exercise in some way to lessen the load on his foot. You’ll probably first ask the player to take off his boot and socks. But the heel will look normal. No redness or swelling will be evident. Have the player point to where the pain is the worst. He will probably point to his heel or under his heel on the sole of the foot.

If you go poking around, the most exaggerated response from the player will be if you squeeze on both sides of the heel. The pain could be greater as you squeeze further along the length of the heel. At this point, you’ll probably suggest that the player go to the doctor who will do that squeeze test and likely take an x-ray (that will probably be normal).

The doctor will bring up Sever’s Disease (so-named for Dr. James Sever who first described this in 1912). Technically, it’s called calcaneal apophysitis, which is an inflammation of the growth plate of the heel (calcaneus).

During puberty, long bones grow in length from the middle out and from the ends in, meeting near each bone’s end at a line called the growth plate. The calcaneus is not a ‘long bone’ so it has a single growth plate. I Googled ‘Sever’s Disease’ for ‘images’ that you should be able to see the growth here to see where the inflammation occurs. It is interesting that the heel’s growth plate grows faster than do the growth plates of the legs so Sever’s disease generally occurs before a child’s ‘growth spurt’.

This type of heel pain occurs during puberty in response to overuse in a player who is unprepared for a rapid increase in training load. Most often, the pain begins early in a training cycle, typically in the preseason. A player who has been doing little more than playing video games now goes out to train with his soccer team. The sudden increase in load on growing bones and tendons can lead to inflammation. Athletes who overpronate (foot rolls ‘in’) while running get this more than those who don’t pronate. And it can happen in both heels at the same time. Over half of athletes with pain in one heel will have pain in the other heel, too.

Most overuse injuries are preventable with some preparation. Ease into the new season by doing some running (stay off a road or sidewalk) and other soccer-specific activities in the 2-4+ weeks before formal training begins. Do plenty of stretching of the legs, calf, and feet. And don’t skimp on the shoes. Good fit, plenty of firm support, and a shock absorbing sole. Soccer shoes generally don’t meet those criteria so only wear studded boots when training gets competitive (for small sided games, scrimmages). Wear a good running shoe for all other aspects of training. In athletes with the most pain, the physician might suggest a short period of immobilization.

Once diagnosed, there are several treatments that should be helpful. For example, stretch the hamstrings and calf 2-3 times a day, consider pulling out the sock liner (the insert that comes with the shoe) and replacing it with an orthotic (custom orthotics can be quite expensive and are rarely covered by insurance. Look for an over the counter orthotic that is soft, to absorb shock, and that elevates the heel a bit).

A physician might say to ice the heel(s) in the morning, consider physical therapy, and may suggest a non-steroidal anti-inflammatory drug (usually products that contain naproxen sodium). After training, remember the tried and true RICE (rest, ice, compression, elevation). When not exercising or training, try to wear shoes with an open back and the lowest heel possible.

The outcome is predictable. Sever’s disease is a self-limiting condition. This means that the pain will go away with a reduction in activity or once the bone has stopped growing. Any long-term disability is not expected. In most children, pain will subside in two or more weeks. But a rapid return to the previous level of training may well cause the pain to return, so ease back into any activity.

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