Heel pain as a result of [Traction Apophysitis->@case-histories] is usually debilitating. I wrote about this on 3 April, 11 February and 8 February. The progress report and full case history is now on the website under [Case Histories->]. Although this section is of greater interest to other health professionals, have a look at the X-ray pictures.
They were reported as normal – we could debate that – but what IS important is the improvement in the state of the bone after 3 months of care.
I have just seen the 8 year old child with Traction Apophysitis featured in previous posts. Since January 26, when I first saw him, he has followed a strict programme of reduced activity.
He has been fantastic in wearing trainers at school – remember that all the other children are barefoot – and severely limiting or stopping any activity that caused pain. Although, about a month ago we did let him start swinging a golf club at the driving range!
His mother reports that he no longer sits on the side of the bed in the morning rubbing his painful feet. Has no pain after school, even though he has recently started playing some soccer at break time and he is completely pain-free.
Today’s X-rays show a normal appearance of the calcaneal epiphysis (the growth area/point at the back of the heel), and improved bone density.
The plan now is to slowly start activity again and that will be rugby.(He plays barefoot). The trainers must still be worn as often as possible. Follow up will be in 6 months.
The diagnosis of Traction Apophysitis is usually based on the presenting clinical symptoms, as the X-ray findings are often inconclusive. Nevertheless we must never ignore the younger child with painful heels and always consider Traction Apophysitis.
Management is clearly “rest”, by reducing or avoiding those activities that cause pain. A supportive but soft/cushioning trainer is the best footwear. There is a place for short term anti-inflammatories followed preferably by topical gels and plasters.
Whatever we try, there is always the question of ‘what would have happened if we had done nothing?” I believe that that decision can only be made with the individual patient in front of you, so that you can respond with clinical judgement and personal empathy. However there is no doubt that for many children it is a transient condition.
My apologies for not getting the case history on the site as promised.
THE COMPLETE CASE HISTORY WILL BE ON THE WEBSITE SOON.
How much sport is enough for a child? When does too much sport become abuse? Is an over-use injury at a young age, in the pursuit of excellence worth the possible long-term consequences? Consider this:
Last week, an 8 year old boy, barely able to walk, was brought to see me by his mother. He had a severe limp, walking with his foot out and his ankle stiff, to reduce the pain. Three days previously he had spent nearly 5 hours doing athletics at school. His mother told me that the initial pain began more than 6 months ago, after he had played a lot of rugby.
The school under 8 team had been very successful, winning their area age group, so had a long season. Then he moved up an age group to under 9 which extended the season further. Nevertheless he continued with all sports, despite the pain and the fact that he was not running as fast as before. A compounding factor is that athletics and rugby are both done barefoot.
The timetable of sports reads like that of a professional adult, with daily practice depending on the sport and season, with inevitable overlap; plus the fact that the school plays some sports out of season as well.
The boy is obviously very good at his sports and according to his mother is always active at home whilst playing. However, this timetable with an injury would cripple most adults.
So what’s the point? How far must we/should we push or allow our children in pursuit of sporting excellence? We try to teach balance in most aspects of life, sleep, study, money etc., but when it comes to sport we seem to make up the rules as we go along.
After requesting X-rays of both feet and discussing them and my diagnosis with two different medical colleagues, it was agreed that the cause of the pain is damage to the growing part of the back of the heel bone, where the Achilles tendon inserts. Clinically called a Traction Apophysitis.
The initial treatment is rest and avoiding any vigorous activity that causes the Achilles tendon to pull on the heel bone. Raising the heel or possibly orthotics may help.
So ask yourself the question – is this youngster suffering an over-use injury or child abuse or both?
A full Case History will be posted during this week.