When I was a kid, both of my parents were trained nurses so to get a day off school was next to impossible. In fact, I heated up a thermometer under boiling water once just to prove I had a temperature! But as it turns out, having a temperature of over 50° and still be functioning is pretty hard to believe! And as a mum myself, I’ve often won the title of mother of the year for not quite believing my son when he suddenly has a sore eyelash when he has an assignment due. But sometimes, kids are telling the truth when they say they’re in pain! And if they’re complaining about a certain kind of pain at certain times with certain specific characteristics, then I might have some answers for you!
Introducing Sever’s disease. Sever’s disease is one of a group of issues that can happen to kids as they move into adolescence. It’s correct name is actually tractional apophysitis of the calcaneus which is more of a mouthful but much less scary than a disease. And more fitting as it literally means a pulling force that causes inflammation near a growth plate. In the case of tractional apophysitis of the calcaneus (I’m going to call it TAC to save my fingers) it is when the Achilles tendon pulls on the back of the heel bone where there is an open growth plate.
TAC happens to kids between the ages of 8 and 14 as this is the time when the heel bone itself goes through a period of growth when it changes from cartilage to bone. There are a few very specific characteristics that can set this sort of issue apart from generalised sort of aches and pains. I will go through what to look for so that you will know when the kids are not just trying to get out of washing the dishes!
TAC is essentially pain at the back of the heel. It can happen in one foot or both at the same time. Kids will usually complain of a sore heel but when you have a poke around they could be sore all around the heel, right at the point where the Achilles attaches or even up into the tendon itself. The pain usually happens when they are being active and it is more common when doing high impact stuff like running and jumping. It begins during activity and often gets worse after they stop running around! You might notice that your child is limping or walking on their toes to avoid that sore heel.
So, if every child has a growth plate in their heel that is changing between the ages of 8 and 14, why doesn’t every child get heel pain? There are a few factors that can make it more likely to be an issue…
High levels of activity; especially high impact activity
Kids who play a lot of sport or certain kinds of sports can be more susceptible to TAC. Sports that involve lots of running, jumping/landing and changes in direction such as soccer, netball, basketball and football are common offenders. Hard playing surfaces/poor footwear choices can also increase the level of impact.
2. A sudden increase or change
If I had a dollar last year for every child I saw with sore heels, I could be sipping pina coladas on a beach somewhere this year! Why? Because COVID had everyone locked down. Most sports were cancelled for quite an extended period of time, kids weren’t going to school and running around at lunch and they were not moving around as much as they normally would. Then COVID settled down and all the kids launched happily back into their sports and school activities. This sudden change in activity created an avalanche of sore heels. This stop/start pattern is one that is easy to identify. But it can also be a change in the type of activity (swimming to running), a change in the volume/frequency of activity (3 training sessions instead of 1), a change in intensity (rep teams vs club teams) a change in the child’s height or weight or even a change in playing surfaces or shoes.
3. A foot type that sits outside the ‘normal’ range
Feet come in all different sizes and shapes. A lot of these differences are measurable and can then be classified as inside or outside of the normal range. One of the things we look at with children is whether they have a high or low arch. Traditionally, children with low arches have been linked to greater risk of TAC. But as a clinician, I see just as many kids who have very high arches who get sore heels. Either way, high or low, it creates a greater tensional strain on the Achilles tendon which can lead to TAC.
4. Tight calf muscles
The largest of the calf muscles, the gastrocnemius, is the muscle that turns into the Achilles tendon. So it makes sense that if you have a tight calf muscle, it would increase the tugging force on the heel bone where the tendon is attached. Tight calf muscles may go unnoticed for years too as they often don’t cause discomfort. But if your child can’t touch their toes, has a ‘bouncy’ walk or walks with their toes pointing outwards, there’s a good chance they have tight calves.
So we now know the what and the why. Now for the how do we fix it. The good news is, using some simple interventions, TAC will likely self-resolve in time. Basically, if we can find out what is causing it, we can fix it! Sometimes treatment will involve education, activity modification and load management. Sometimes we need to address the biomechanical issues (the measurements that put us inside or outside of the normal range) by prescribing custom foot orthoses.
But the best thing to do if your child is complaining about sore heels is to bring them in to see a podiatrist. They can complete a full assessment, devise an individualised treatment plan to get your tin lids back to their active lifestyle (and out of your hair!) as quickly as possible!
