Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

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Filtering by Tag: heel pain in children

Pointing Out the Top 10 Pediatric Sports Musculoskeletal Injuries

The Top 10 Sports Musculoskeletal Sports Injury list is a ranking that I'm guessing most athletes don't want to make, and most parents don't want to miss.

How to best know if you belong on this list?

Trust your finger tips.

Speaking at the 2016 American Academy of Pediatrics National Convention and Exhibition, I was asked along with good friend and colleague Hank Chambers to share insight on identifying and managing the Top 10 Pediatric Sports Musculoskeletal Injuries with a Case-Based Review.

Our Top 10 aptly started at the top of the body (neck) and ran down to the bottom (foot/ankle) with several injuries in between.

We looked at:

Some were fairly serious and activity threatening, others were more of a nuisance.

A pretty diverse offering of injuries, so one would tend to think that there would be little that actually brings them together.

However, for those listening to the talk, they heard us mention a similar refrain over and over again.

The value of your finger tip.

In helping to determine a type of pain that merits medical attention in the first place, and helps sort out the particular diagnosis, the more localized the pain, the greater the potential concern.

For example,. if a child is reporting pain in the lower leg and uses a wave of the hand to indicate that the discomfort runs along the entire inner shin, then there is one level of concern.

However, if that same child takes the tip of their index finger and points directly and emphatically to a single spot on the inside of the shin bone, my concern is amped up several degrees.

While none of us have x-ray vision, that finding of finger-tip pain is a pretty good surrogate and does tend to correlate with a higher potential of a bone injury, be it a fracture, stress injury, or damage to a apophysis where a tendon attaches to a bone growth region.

So, no matter the body part, from elbow to wrist to foot or ankle, if any young athlete opts to use a finger tip to identify their pain, then use your finger tips to dial up your sports medicine specialist and seek out immediate and appropriate evaluation.



Healing Young Athlete's Heel Pain

One of the most common concerns young athletes and their families bring to my attention is heel  pain.

Tends to bother the back of either one or both heels and can range from a little discomfort after exercise to something that creates limping,  decreased speed, and pain for both the athlete and parents. Usually not much in the way of swelling or numbness, but sure can be uncomfortable with running, landing from jumps, squatting, or just plain touch. Not caused by one fall or awkward landing, but rather has a gradual onset without known trauma.

Kids who are the most likely candidates for this type of heel pain tend to be:

  • entering growth spurts in later elementary and middle school ages
  • playing multiple running and jumping sports at the same time
  • starting a new season or activity where more conditioning (ie: running lines) takes place
  • ending a season where cumulative fatigue begins to kick in
  • playing on hard surfaces (yes, the on-going California drought and resultant harder fields has not helped)

The usual cause of the pain is irritation of the Calcaneal Apophysis (aka Sever Syndrome or Sever Disease), which involves the growth area in the back of the heel bone that is connected to the calf muscles through the Achilles Tendon. Tightness of the calf muscle-tendon unit, often seen with those growth spurts, combined with repetitive impact on the heel will lead to the pain and limping initially after and eventually even with exercise activity.


I usually don't get x-rays with this problem (since they don't tend to change my treatment recommendations), but if obtained, often see a somewhat "ratty"or irregular look to the growth area at the back of the heel that is normal during periods of growth.


In adults, pain the in the back of the heel  tends to be from irritation of the midsubstance of the Achilles Tendon or from the origin of the Plantar Fascia underneath the heel bone. In growing kids,  the weakest link is the calcaneal apophysis growth area, and while this is no fun to experience,  treatment options actually are more efficacious and quicker to show effect than with the adult versions of heel pain.

Patients who receive the diagnosis of Calcaneal Apophysitis leave my office with homework- a list of calf stretches that if done diligently and correctly, will correct the pain  and allow full return to activity of choice.

  • Each stretch should be done four times a day (best of after at least some walking around to warm up muscles)
  • Each stretch position should be held for 15-30 seconds and repeated for a total of three times on each leg.
  • There should be no bouncing, holding of breath, or extreme pain
Knee straight- pull foot back toward shin

Knee straight- pull foot back toward shin

Back leg with heel pushed into ground and knee fully straight

Back leg with heel pushed into ground and knee fully straight

Back leg with heel pushed to ground, knee partially bent

Back leg with heel pushed to ground, knee partially bent

Let heels drop off step, hold on banister for safety

Let heels drop off step, hold on banister for safety


The stretches are the backbone of recovery- failure to do them often leads to incomplete resolution of pain. In fact, if all the child did was perform the above stretches as recommended, a fairly quick recovery within 2-3 weeks often occurs.

There are some additional recommendations that can assist the stretches in reducing pain:

  • Heel cups or wedges can be placed in all pairs of shoes (school and athletic) to act as shock absorption for the heel
  • Ice massage- fill a small paper cup full of water, freeze overnight, then rub the ice block against the heel with some pressure to reduce pain and loosen up the soft tissue in that area
  • Will allow occasional (1-2 time/week) use of acetaminophen or ibuprofen to reduce pain.

Often get asked about ability to return to play with heel pain. Since most cases of properly diagnosed calcaneal apophyseal pain are more nuisance issues than potential  long-term problems, I will allow most kids to continue playing as long as they do their stretches. Situations that may lead me to limit activity for a week or two might include:

  • Pain not just during or immediately after activity, but rather lasting all day and even into the next day
  • Significant  limping or change in running/jumping technique that is painful for parents and others to watch
  • Pain not getting better despite stretches
  • Athlete/family desire to get pain to go away "as quickly as possible"

Now, there are several other conditions, including fractures, infections, and other more serious problems, that may appear similar to Calcaneal Apophyseal pain, so getting an expert opinion and not relying on self-diagnosis is strictly recommended. This is especially true with any case of fall, trauma, immediate onset of pain, swelling, or pain not getting better or quickly returning after trying stretches and rest. This blog post is not intended to diagnose or provide treatment recommendations without the guidance and expertise of a qualified sports medicine specialist evaluation.