Traction Apophysitis

Introduction

26-01-09 Male child aged 8yrs 8 months presented with acute disabling pain behind and on the inside of his left heel. His mother informed me that 3 days prior to visiting me, the boy had participated in a school athletics meeting involving trials, followed by competition for about 5 hours. After which he had been carried home because he was in such pain.

History

In 2008, he was playing under 8 rugby for his school. The team was so good that they had an extended season, due to winning various competitions. This was followed by a change of age group – he turned 9 in May 2008 – resulting in an even longer season. This involved playing junior rugby at Provincial level.

The boy admitted to “feeling something go in the foot” during the 2008 rugby season.

Additional sports activity activities included cricket for school and on Saturdays for a university junior side, plus athletics for school. The seasons for these sports overlap at this boy’s school and even run concurrently.

All sports are performed barefoot.

Typical activity timetable of hours spent on sport*

	Athletics	Cricket	Rugby
Mon	1	1.5	1
Tues	1	1.5	1
Weds	1	1.5	1
Thurs	1	1.5	1
Fri	1	1.5	1
Sat		2

*Plus meetings and matches

Examination

Prior to the acute incident, it was painful to put the foot to the ground on getting out of bed every morning.

The point of pain was elicited infero-medially to the heel pad, (where a calcaneal spur or enthesitis would be in an adult), only on the left foot. There was no complaint of pain when palpating the estimated line of the calcaneal epiphysis, or posteriorly at the insertion of the tendo-Achilles.

A severely antalgic gait was observed, with the most comfortable position of the left foot being in extreme abduction and avoiding ankle dorsi-flexion. Toe walking relieved the pain.

Joint ranges of motion (ROM): On the tip-toe test inversion of the subtalar joint was noted, eversion of the subtalar and midtarsal joints was limited. Normal passive ROM was found in the hips and knees.

There was no evidence of increased local callus to suggest abnormal foot biomechanics. Physiological callus was present, due to the barefoot walking at school and during sport.

Differential Diagnosis

Traction Apophysitis

Early Severs’ Disease

Tendon or fascial tear or rupture

Epiphysial fracture or avulsion

Focal aseptic necrosis

Management Plan

X-ray of both heels

Stop all sporting activity

Wear shoes or trainers for school (normally barefoot)

Findings

28-01-09 A normal X-ray was reported

29-01-09 Presentation and X-rays discussed with Professor of Rheumatology and Paediatric Rheumatologist

Click to Enlarge

Diagnosis

Traction Apophysitis (avulsion)

Follow up

During February and March the patient adhered to the programme of rest and footwear (thanks to great support from his parents). A branded supportive trainer was worn. Did a little golf at the driving range after one month.

03/04/09

X-ray showed more normal ossification with increased bone density and reduced fragmentation.

Click to Enlarge

On examination, the patient was asymptomatic, playing soccer at school break time barefoot. Still doing driving range golf, plays normally with friends and on the trampoline a little.

PLAN

Return to rugby slowly and see if symptoms return.

Continue to wear trainers as much as possible.

DISCUSSION

According to the literature, traction apophysitis is a common condition, but is hard to diagnose using only X-ray, because of its close resemblance to normal. For this reason, the diagnosis is mainly made on clinical suspicions, plus individual signs and symptoms.

Pathophysiology

The primary calcaneal ossification centres are usually united at birth. The posterior aspect of the bone develops an irregular wavy outline at about 4 years of age.

The principal secondary centre, located in the posterior calcaneus, begins to develop around 6 years of age. It ossifies from many fragmented areas and is typical of the irregular mineralization of epiphyses generally.

The X-ray picture of the developing posterior calcaneal epiphysis is one of many centres; sclerosis and fragmentation of the apophysis are common as part of the normal growth pattern.

This area normally ossifies in boys at 4-9 years. Secondary centres in the apophysis may occur in boys up to 11-15 years.

Clinical Presentation

Despite the X-ray report of normal, there are features of the bones that appear abnormal.

Note the jagged posterior margins of the posterior surface of both calcanei.

The completely detached posterior portion of the calcaneus.

The presence of a medial spur.

Apparent atrophy and loss of density

The right appears to have some attachment between the bony fragments.

Key diagnostic aids

History of injury – but it is usually repeated trauma

Child points directly to the area

Possible referred pain

Pain may or may not be elicited on pressure

Pain is precipitated by walking and exercise

Management

Rest and reduction of any activity which increases tension on the heel

Treat any underlying biomechanical cause

Cushioning and raising the heel

Wear firm (not hard) supportive footwear

This case

The history of excessive sport appears to have been the primary cause in this

case. After the initial onset of pain, the increased pressure to continue with a winning team contributed. Many children who achieve well in their sport try to ‘go through the pain barrier’ and in some cases are pushed by their parents.

(Not so in this case – they just took a long time to react).

Due to the trauma there was significant delay in the normal ossification process and this is visible on the X-ray – when read in conjunction with the trauma from sport overuse.

Although the literature and personal clinical experience shows that most cases of traction apophysitis are self-limiting and resolve without treatment, the management of this case and subsequent recovery, illustrates the benefit of a cautious intervention and the cooperation of all concerned.