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Wondering if someone can give me a bit of a heads up on this....

12 year old - heel pain, good biomechanics and no gastro soleus tightness though is highish tone. Good neurological. Pain on medial lateral pressure of the apophisis. Got these x-rays taken that were "normal" after heel raises, massage, fascia taping, RICE and analgesia, rest form sport haven't changed a thing in 3 months.

(hope they work) - saw when reviewing them again last week an ineresting posterior talus - looks mushy, not reported on by radiologist, and I only just noticed in frustruation...this isn't a growth plate in this area.....after no injury - what could this be?
Here's the links......



Second one

Hi.
Severs?

If so you should address the mechanics. I would be very suprised if, when you re-examine, you don't find a mild frontal plane difference in pitch between the FF and the RF.

Regards,
david

These simple, inexpensive, self-molding heel cups come in two sizes--child and adult and they work extremely well while allowing resumption of activity. X-rays of "Severs" apophysitis cases are always reported as normal so x-rays are NOT diagnostic - - but pain on medial-lateral compression in the absense of trauma IS diagnostic in kids aged 9 to 13, in my opinion....

Thanks for that guys but have been treating it like sever's for 3 month, have also tried the heel cups - no change. Also had another pod opinion and even a physio opinion - there is just good biomechanics all round......

I'm wondering though if it could be something referred from the talus and if so what could be the radiological change that is shown on the x-ray??

Think it might be off to a sports med Dr.....

Hi.
With respect, I think you will find a FF to RF twist in the foot if you examine closely.

Your brief case history strongly suggests Severs. Look for the biomech anomaly.

Be interested in your findings.
regards,
david

Aprreciate your time David. We strapped this kid also to "improve " I suppose the position he already has - no difference - seeing him strapped over a 3 week period......

Is this is sever's it's like nothing I've seen before and I've had heaps through my door.... :( but will definatly look again....never say never

What do you make of the x-rays???

Hi.
I don't use strapping - in my opinion it's not a great modality, except perhaps in pro/high-calibre sports as a (very) temporary measure.

I always use rigid functional orthoses on my Severs cases - that usually works fine.

The x-rays look normal to me.

regards,
david

The diagnosis is calcaneal apophysitis until proven otherwise....when you hear hoofbeats, think a horse, not a zebra!! The radiographs are normal.

My youngest son, who played on a traveling soccer squad from the ages of 8-14, had a year of pain in his heel at age 12 from soccer (which I diagnosed as calcaneal apophysitis) but only got slightly better with heel cups, icing and stretching that he tried for a year. It wasn't until I broke down and made him a plastozote #3 foot orthosis with a full length Spenco topcover that he made significant improvement...he became asymptomatic in 3 weeks!! (His Dad obviously was treating his patients better than he was treating him.)

Heel cups and heel lifts don't work near as well as a flexible shank dependent orthosis with a Spenco topcover for resistant cases of calcaneal apophysitis. I don't think the rigid shell materials work as well for this condition and I always use a Spenco topcover to help cushion the apophysis.

If the orthosis doesn't work, then placing the child in a weightbearing fiberglass cast for 4-6 weeks will generally do the trick. 12 year olds that are very active and athletic with resistant cases of calcaneal apophysitis sometimes need immobilization casting to get them to slow down enough to allow themselves to heal. Also tell the parents to chill out a little to prevent them from injuring their children from too many sports at too young an age in the hopes that their child will be the next David Beckham.

By the way, a child with perfect biomechanics can get calcaneal apophysitis just from overactivity due to the shearing strain at the calcaneal apophysis much in the same way that an adult runner with perfect biomechanics can get Achilles tendinopathy if they run too hard and too fast due to the tensile stresses on the Achilles tendon. One doesn't need to find "deformities" to know what caused the pain. One only needs to know the anatomical location and model the forces on the specific structural component to know what the most likely "cause" of the pain is. Think tissue stress, not "foot deformity", to become better at treating mechanically-based musculoskeletal pathology of the foot and lower extremity.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

You sound like a rare breed in the para-medical profession. Enough dare and pragmatism to try 'different things'; yet not threatened enough to ask for help within the profession and outside of it.

The only thing I will add is that fascial taping would on one hand provide the biomechanical correction (whole or partial) you desire; however, it would provoke in the same way that your medio-lateral compression test did. Not much heals while pain exists. We must stop it (break the cycle).

I would try biomech correction without the medio-lateral constriction of the low-dye taping. Heel wedging is thought to have a very minor biomechanical effect; but I disagree, in view of Kevin's force application and magnitude common-sense. You could go straight for the orthoses, however you appear to have the cost-benefit issue in mind.





The physiotherapist should/would have come back with additional diagnostic testing results. For instance, if your 'mushy posterior talus' hunch is correct, then end-range plantar flexion would be painful and impinge posteriorly.




BTW, the left posterior talus does look different to the right. Is this a unilateral presentation clinically? Is it indeed the left?

Thanks for the rest of the input.

As I work in Community health I have the luxury of a numer of health professionals to consult with - great for outcomes for clients and hope that I am not that rare, Atlas..... would hope that more would work like this is were able.

Cost is a big issue here for the parents so we are have been trying the little things. Considering they get to pay $6.50 to see me - the consultations are the easy thing. Have gone for a flexible orthotic device (just saw your post tonight Kevin, glad I'm on the right track there...didn't put a cover though) but also as there was some pain on forced plantar flexion of the left and the pain is much greater on the left side - sent back to the GP for a bone scan.

Parents are more than happy for this kid to cease sport immediatly but the look on this kids face is enough to break everyones heart when you tell him that - it's just such a comprimise at the moment. He's more than happy to keep going but mum can't stand seeing him limp!

Will see what happens from there.....have a feeling though this kid may end up in plaster....it just not like any sever's encountered before.

Appreciate everyone input!

I have found the extra cushioning from the 3 mm Spenco cover to be helpful for these kids with Sever's Disease. I would add this to his orthoses.

Sounds like the parents have the correct attitude. That is very good.

Now, in order to deal with a young boy who "can't be told to stop" I will speak directly to the boy, not the parent, during the examination. You should tell him directly that you understand he loves sports and that you know he doesn't want to quit playing. However, you must also tell him that unless he slows down and/or uses a cast that he may suffer permanent injury that affect his ability to play sports in the future. Even the most motivated young athlete will understand your emphasis in a short rest break from sports as long as you show that you empathize with his situation and that you are confident it will help. The parents will appreciate you for taking this burden off of their shoulders also.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

I agree completely with Dr. Kirby.

With severe recalcitrant cases of calcaneal apophysitis, immobilization of the affected extremity will give the patient time to heal themselves. If all else fails, casting or CAM walker with NWB usually works well.