Version May 2024
INTRODUCTION — This topic will provide an overview of the causes of heel pain in active children and skeletally immature adolescents.
The evaluation of foot and ankle pain and causes of pain in other parts of the foot and ankle in active children and skeletally immature adolescents are discussed separately as follows:
●(See "Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation".)
●(See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes".)
EVALUATION — Heel pain in children and skeletally immature adolescents can originate in the bones (fractures), ligaments (sprains), muscles and tendons (tendinitis), fascia, skin, or nerves.
Careful history and physical examination with localization of the pain can often identify the underlying etiology (figure 1). In many patients, imaging is not necessary to establish the diagnosis.
Evaluation of the foot is discussed in greater detail separately. (See "Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation".)
ACUTE INJURIES — Common acute heel injuries include friction blisters, open wounds, and contusions. Calcaneal fracture or Achilles tendon rupture is rare in children.
Friction blister — Friction blisters are intraepidermal blisters that result from trauma-induced separation within the epidermis. They most frequently occur on the heels and soles of the feet due to friction from shoes and socks during walking or running. Moisture (eg, from sweating) and pressure points typically caused by poor-fitting or new foot wear increases the frictional forces applied to the skin and predisposes to blister formation [1,2]. Pain occurs when pressure continues to be applied to the fluid between the skin layers.
Blisters can be prevented by emphasizing proper mechanics, ensuring that shoes fit properly and that socks stay dry. Socks that wick moisture away from the skin (eg, acrylic, polyester, or wool socks worn over polyester socks) also decrease the likelihood of a blister [2-4].
Application of preventive tapes and pads to the heel can also provide a friction barrier and can prevent blisters when applied prior to the activity (eg, running, hiking, sports participation) or when skin irritation is present but a blister has not formed (sometimes called a "hot spot") [4]. However, several aspects warrant emphasis:
●The foot should be clean and dry at the time of tape application.
●Adhesive (eg, benzoin or adhesive spray) applied to the skin enhances tape grip.
●The tape should be applied so that wrinkles are avoided.
●The tape should be left in place as long as possible.
Options include micropore paper tape, Blist-O-Ban, Elastikon, and moleskin.
Ointments (eg, petrolatum) or foot powders have not been shown to reduce the development of blisters and may actually increase the risk based upon the tendency to increase friction coefficient with time [4]. Antiperspirants (eg, 20% aluminum chloride hexahydrate spray) can decrease blister formation but frequently cause skin irritation and are not routinely recommended [5].
The treatment of blisters depends upon the size of the blister and the degree of impairment [4,6]:
●Small blisters – Small blisters that are minimally painful can be cleaned and taped as described above.
●Large or painful blisters – Large or painful blisters should undergo fluid drainage while maintaining the roof of the blister as a biologic bandage as follows:
•Clean the intact blister with isopropyl alcohol or other suitable antiseptic solution.
•With a sterile needle (eg, 22 gauge), puncture the blister distally and away from the midline. Use multiple holes rather than one big hole, as needed, to fully drain the fluid but decrease the risk of unroofing the blister.
•Gently express the blister fluid until the blister is flat.
•Dry the skin over the blister and apply paper tape so that it overlaps the edge of the blister.
•Apply benzoin adhesive to the paper tape and cover it with elastic tape.
●Unroofed (open) blisters – Open or broken blisters should be managed as follows:
•Trim off the roof of the blister to prevent further friction as the dead skin hardens.
•Cover the base of the blister with a blister pad designed for open blisters (eg, Spenco 2nd Skin or Band-Aid Advanced Healing Blister).
•Cover the blister pad with paper and elastic tape as described for large blisters above or, for large heel blisters, make a heel cup out of elastic tape (figure 2).
With proper treatment of blisters, children and adolescents should be able to participate in activities without restriction. Dressing should be soaked off and the blisters inspected daily until healing has occurred followed by reapplication. The caregivers should be advised to watch for signs of infection, including redness, increased pain, swelling, and pus drainage and to seek prompt medical attention if they occur.
Plantar puncture wound — Plantar puncture wounds involving the heel are a common injury. Typical objects causing these injuries include nails, pins, other metal objects, wood, stones, and glass. These wounds have a significant risk for infection. When evaluating plantar puncture wounds in children and adolescents the clinician should determine when the injury occurred, whether the patient was barefoot or wearing shoes, and what object caused the wound, if known. The wound should be examined with the patient prone to be able to assess it completely. (See "Infectious complications of puncture wounds", section on 'Epidemiology' and "Infectious complications of puncture wounds", section on 'Diagnosis'.)
Imaging is warranted when there is a clinical suspicion of a retained foreign body. Plain radiographs can detect many radiopaque foreign bodies (eg, glass, stones, or metallic objects). Wood, plastic, and other radiolucent objects can be located with ultrasound. Computed tomography (CT) and magnetic resonance imaging (MRI) are also helpful methods of localizing a retained foreign body when plain radiographs or ultrasound fail. MRI cannot be used when metallic objects are present. (See "Infectious complications of puncture wounds", section on 'Diagnosis'.)
The management of plantar puncture wounds depends upon the presence of infection and is discussed separately. (See "Infectious complications of puncture wounds", section on 'Prevention' and "Infectious complications of puncture wounds", section on 'Management'.)
Laceration — Plantar lacerations of the heel warrant assessment, debridement, and treatment according to the general principles of wound management. Typically, nonabsorbable sutures are used for wound closure and are kept in place for approximately 10 days. (See "Minor wound evaluation and preparation for closure" and "Skin laceration repair with sutures".)
Lacerations to the sole of the foot frequently involve cuts caused by sharp objects that the patient steps on while barefoot and foreign bodies are an important consideration. Imaging is warranted when there is a clinical suspicion of a retained foreign body. Plain radiographs can detect many radiopaque foreign bodies (eg, glass, stones, or metallic objects). Wood, plastic, and other radiolucent objects can be located with ultrasound. CT and MRI are also helpful methods of localizing a retained foreign body when plain radiographs or ultrasound fail. MRI cannot be used when metallic objects are present. (See "Infectious complications of puncture wounds", section on 'Diagnosis'.)
Relative to wounds on other parts of the body, lacerations on the heel are more painful to anesthetize by local injection. A posterior tibial nerve block provides an alternative approach that may provide better pain control during the procedure. (See "Lower extremity nerve blocks: Techniques", section on 'Ankle block'.)
Lower extremity wounds are more prone to infection than lacerations with better perfusion (eg, face or scalp lacerations). Thus, patients should have a wound check within a few days of wound closure and should be given careful instructions regarding proper wound care, including no swimming, no immersion while bathing, and monitoring for infection. (See "Skin laceration repair with sutures", section on 'Aftercare'.)
Contusion — Contusion of the heel, sometimes referred to as a heel pad or foot pad contusion, can be caused by acute trauma (eg, landing from high fall) or stepping on a root or rock during hiking or trail running. Examination reveals focal soft tissue tenderness at the plantar surface of the mid portion of the heel (not at the insertion of plantar fascia, which suggests plantar fasciitis). This is where the os calcis is most prominent and thus, at higher risk of contusion.
The management of heel contusions is discussed in more detail separately. (See "Evaluation and diagnosis of common causes of hindfoot pain in adults", section on 'Heel contusion'.)
Calcaneal fracture — Clinical presentation of a calcaneal fracture depends upon its location and the severity of the injury. Most calcaneus fractures result from significant trauma, typically an axial loading of the foot following a fall or jump from a height. Pain is usually quite severe and weightbearing is often impossible. Swelling and tenderness are typically evident and may be severe. Deformity of the heel may be apparent. The physical examination should include vital signs and a careful evaluation looking for signs of internal injury, particularly for patients involved in high energy trauma (eg, fall from height). Typically, patients with a calcaneus fracture from high energy trauma manifest tenderness around the heel and hindfoot. Areas to palpate include the tuberosity, body, and anterior portions of the calcaneus. (See "Calcaneus fractures", section on 'Mechanism and clinical presentation'.)
Calcaneal fractures are diagnosed on the basis of imaging studies. Radiographic evaluation of a suspected calcaneus fracture begins with plain radiographs, including lateral and axial views (image 1 and image 2 and figure 3). Additional views and CT are obtained when clinicians require greater detail about the extent of the fracture or when there is concern for an occult fracture despite nondefinitive initial radiographs. In addition, half of the patients with a calcaneus fracture sustained during a fall or other high-energy trauma have concomitant injuries, including fracture of the contralateral calcaneus and compression fractures of the thoracolumbar spine (image 3A-B), and areas of concern based upon the clinical evaluation should be imaged [7,8]. (See "Initial management of trauma in adults".)
The diagnosis and management of acute calcaneus fractures are discussed in greater detail separately. (See "Calcaneus fractures", section on 'Diagnosis' and "Calcaneus fractures", section on 'Extraarticular fracture types' and "Calcaneus fractures", section on 'Intraarticular fracture types'.)
Achilles tendon rupture — Achilles tendon rupture occurs rarely in children or young adolescents. Case reports have described direct trauma to the posterior heel that directly or indirectly disrupts the tendon [9,10]. With rupture, patients often report severe pain at the back of the ankle and have difficulty bearing weight. Some also describe a "pop". However, the absence of pain does not rule out rupture. Physical examination may show a gap in the tendon contour compared with the unaffected side and a proximal nodule in the calf. The calf squeeze or Thompson test (picture 1) demonstrates no plantar flexion when the gastrocnemius muscle is squeezed. An MRI can be performed for further evaluation if an Achilles tendon rupture is suspected. (See "Achilles tendinopathy and tendon rupture", section on 'Physical examination'.)
The treatment of Achilles tendon rupture is discussed separately. (See "Achilles tendinopathy and tendon rupture", section on 'Treatment'.)
OVERUSE INJURIES — Calcaneal apophysitis (Sever disease) is one of the most common causes of heel pain in children and young adolescents. Other important causes include plantar fasciitis, painful heel pad syndrome (heel contusion), Achilles tendinitis, retrocalcaneal bursitis, and calcaneal stress fracture.
Calcaneal apophysitis (Sever disease) — An apophysis is a growth plate that does not contribute to the linear growth of the bone. The calcaneal apophysis, located on the posterior inferior aspect of the calcaneus, is the growth plate at the insertion of the Achilles tendon (figure 1). It normally develops at an earlier age in girls than in boys (six versus eight years of age, respectively) and is present for approximately three to four years. The calcaneal apophysis displays increased metabolic activity during periods of rapid growth, which can place it at risk for overuse injury. Factors that can lead to this injury are: participation in sports or other activities that involve running or jumping, abnormal heel striking that can result in repetitive microtrauma to the area [11], and excessive traction placed on the area by the Achilles tendon.
Calcaneal apophysitis is one of the most common causes of heel pain in active children, particularly those who play soccer and basketball or participate in gymnastics or track/running [12,13]. In one study, the incidence of calcaneal apophysitis in general practice was 3.7 cases per 1000 patients. The mean age of presentation is 8 to 12 years; boys are affected more often than are girls; the condition is bilateral in up to two-thirds of cases [12,14,15].
●Clinical features and diagnosis – The diagnosis of calcaneal apophysitis is made clinically. The characteristic history is one of chronic heel pain that is related to activity and has an insidious onset [16]. The pain of calcaneal apophysitis may be exacerbated by wearing footwear that lacks heel cushioning or support (eg, flip flops) or athletic shoes with heel cleats (particularly soccer cleats) which center the force of impact on the heel.
The physical examination demonstrates heel pain tenderness during direct palpation over the apophysis (figure 1) or the calcaneal compression test [17,18]. In the calcaneal compression test, the examiner holds the affected heel in his or her palm with the fingers enveloping the upper portion of the heel and then squeezes to compress the heel in the transverse plane. Heel compression will also reproduce pain from a calcaneal contusion, stress fracture, or acute fracture but should not be painful in plantar fasciitis, fat pad syndrome, posterior impingement, or Achilles tendonitis. Related physical findings that may be seen in children with calcaneal apophysitis include decreased gastrocnemius-soleus flexibility, foot pronation, or arch abnormalities (flat foot or high-arched feet) [11,12,16]. In some patients, calcaneal apophysitis may be complicated by Achilles tendinitis or plantar fasciitis [16,19].
●Imaging – Radiographs are not required to make the diagnosis of calcaneal apophysitis but should be obtained to exclude other disorders if the presentation is atypical (eg, inability to bear weight, acute onset, associated constitutional symptoms) or if the patient fails to make appropriate clinical progress with routine management (eg, no improvement in four to eight weeks) [14].
Plain radiographs in patients with calcaneal apophysitis may show sclerosis and widening of the growth plate. These findings are more typical of a developmental stage than of a pathologic process and can also be seen in normal children [14].
MRI is appropriate in patients with normal plain radiographs who have severe symptoms (eg, cannot ambulate four steps) at initial presentation or do not respond to routine management after four to eight weeks [20]. MRI may demonstrate stress fracture of the calcaneal metaphysis in such patients [20].
●Treatment – The management of calcaneal apophysitis is derived from small trials, observational studies, and clinical experience [12,16,19,21-25].
Our approach to initial therapy is as follows:
•Bilateral use of a heel cup or lift (5 mm [0.25 inch]) such as Tuli’s or KidZerts heel cups.
•Decreased level of participation in painful activities, as needed, with a gradual increase once symptoms have subsided.
•Home treatment program emphasizing daily ice packs to the area for 20 minutes along with calf muscle stretching and strengthening.
•Nonsteroidal antiinflammatory drugs (eg, ibuprofen) taken as needed for pain during the initial treatment stage but not before exercise or in order to increase the amount of activity that the patient can tolerate.
For the compliant patient whose symptoms fail to improve within four to eight weeks, imaging with plain radiographs should be performed to help exclude other causes of heel pain and the patient should be referred to a sports medicine specialist. Physical therapy is also often employed at this time to help the patient improve calf flexibility and strength, especially eccentric gastrocnemius strength that will soften heel striking [11]. An MRI may be warranted to identify any additional conditions if a patient fails to improve with these measures. Should physical therapy fail to improve symptoms and imaging is normal, short-leg casting or use of a fracture boot with a rocker bottom sole for three to four weeks may help to resolve painful symptoms related to stress-associated bone changes.
Evidence supporting our initial approach is as follows:
•In two small, randomized trials in boys between eight and 15 years of age, either a rigid heel cup or a lift significantly reduced pain and permitted continued high levels of activity without any other treatment [21,25].
•In a crossover trial that compared the heel cup with the lift in 44 boys, the heel cup reduced self-reported pain significantly more than the lift and was preferred by more than 75 percent of the participants [21].
•In a separate trial that compared a soft, silicone heel lift with activity reduction or physical therapy that focused on calf-strengthening in 98 children, there was no significant difference in reduction of heel pain among the groups [22]. Although patients receiving lifts were significantly more satisfied, satisfaction with treatment was high in all three groups.
Thus, a heel cup may better reduce pain than a lift and activity reduction or calf-strengthening exercises are also efficacious but are associated with lower satisfaction than the use of a heel cup or lift. In recalcitrant pain, clinicians may consider the significantly more expensive option of custom orthotics that have also been shown to be superior to lifts [26].
Plantar fasciitis — Plantar fasciitis is the most common cause of inferior heel pain in adults. It occurs less commonly in children and adolescents, but it does occur in athletes (particularly distance runners and dancers) and in sedentary, obese children. Excessive, prolonged foot pronation is a predisposing factor. (See "Plantar fasciitis", section on 'Epidemiology'.)
Many patients with plantar fasciitis have the "first step in the morning" symptom, in which the pain occurs for the first few minutes after getting out of bed and then improves or resolves. This first step may be easily confused with morning stiffness associated with spondyloarthropathies. As the course of plantar fasciitis progresses, pain may return during activity, following prolonged sitting, or at the end of the day. The patient may report that it feels as if there is a rock in his or her shoe. The pain is lessened if the patient walks on the outside of the foot. (See "Plantar fasciitis", section on 'Common clinical features'.)
The area of maximal tenderness typically is over the medial calcaneal tubercle and, less commonly, into the arch (usually in patients with pes cavus). Pain is best appreciated when the great toe is passively dorsiflexed, causing the plantar fascia to become taut and easy to palpate (picture 2). Examination also should include evaluation for tight gastrocnemius and pes planus because the treatment plan may vary if these conditions are present. (See "Plantar fasciitis", section on 'Common clinical features'.)
Posterior heel pain is not part of the usual presentation of plantar fasciitis, a characteristic that can be used to differentiate it from many of the other conditions that cause heel pain. Inflammation of the medial calcaneal branch of the tibial nerve (a type of tarsal tunnel syndrome) can mimic plantar fasciitis (figure 4). However, patients with this pathology will not have the "first step of the morning" sign, will often manifest a positive Tinel sign (tapping over the tibial nerve causes pain and paresthesia), and may have altered sensation. (See "Plantar fasciitis", section on 'Neurologic causes'.)
The diagnosis, differential diagnosis, and treatment of plantar fasciitis are discussed in greater detail separately. (See "Plantar fasciitis".)
Painful heel pad syndrome (heel contusion) — Chronic heel pain from contusion may occur in runners who use shoes with inadequate cushion. A subcalcaneal fat pad protects the weightbearing surface of the calcaneus. This fat pad has fibrous septae that act as coil-like mattress pads to absorb shock each time the heel strikes the ground. Painful heel pad syndrome may result from disruption of the fibrous septae that compartmentalize the fat in the heel pad. Pain is localized to the heel pad; the plantar fascia is not tender, and pain is not accentuated as the examiner dorsiflexes the toes. Treatment is described separately. (See "Evaluation and diagnosis of common causes of hindfoot pain in adults", section on 'Heel contusion'.)
Achilles tendinitis — Patients with Achilles tendinitis describe pain in the distal tendon about 2 cm proximal to its insertion on the calcaneus (figure 5). Running or jumping will classically irritate it more and is often associated with inflexibility in the gastrocnemius/soleus complex or a remote ankle injury with inadequate rehabilitation. It is more common in skeletally mature patients and is an unusual condition in children and young adolescents. Pain at the insertion of the Achilles tendon at this age may be an important marker for inflammatory enthesitis (eg, juvenile idiopathic arthritis). (See "Oligoarticular juvenile idiopathic arthritis", section on 'Clinical presentation'.)
Achilles tendonitis is discussed in greater detail separately. (See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Achilles tendinitis'.)
Retrocalcaneal bursitis — Retrocalcaneal bursitis may coexist with Achilles tendinitis and causes pain, erythema, and swelling between the Achilles tendon and the calcaneus. Children and adolescents with retrocalcaneal bursitis often are runners or soccer players who have poorly fitting shoes with friction between the shoe and the heel. Local warmth and tenderness behind the Achilles tendon is found on examination.
Management of bursitis is discussed in detail separately.
Posterior ankle impingement — Posterior ankle impingement may cause posterior heel and ankle pain due to compression of the synovium and surrounding structures of the posterior ankle joint. Etiologies include altered ankle mechanics, anatomical variants (large os trigonum), or overuse from activities that bring the heel into plantarflexion (eg, dance, gymnastics). The diagnosis and management of this condition are discussed separately. (See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Os trigonum syndrome (posterior ankle impingement)'.)
Calcaneal stress fracture — Calcaneus apophyseal fractures are relatively uncommon events, but they do occur [27]. Calcaneal stress fractures are the most common stress fracture in the pediatric rear foot and are seen more commonly in runners and in young military recruits [28]. There is a higher frequency in female adolescents who have osteopenia related to inadequate caloric intake and secondary amenorrhea. Heel squeeze may be positive on physical exam. While radiographs may show stress reaction and callus formation, MRI is more sensitive to early changes, but may have false positives that do not correlate with the clinical exam [28,29].
BONE CONDITIONS — Most bone tumors that cause heel pain are benign and include unicameral bone cysts and osteoid osteomas. Rarely, Ewing sarcoma may arise in the calcaneus.
Unicameral (simple) bone cyst — Unicameral bone cysts (simple bone cysts, solitary bone cysts) are fluid-filled lesions with a fibrous lining. Most unicameral bone cysts are asymptomatic and are discovered incidentally on radiograph. However, localized pain and pathologic fractures can occur. Calcaneal cysts that are symptomatic warrant orthopedic referral. (See "Nonmalignant bone lesions in children and adolescents", section on 'Simple bone cyst'.)
Bone tumor — Most bone tumors that present with heel pain are benign [30]. Between 5 and 8 percent of osteoid osteomas occur in the foot. The classic presentation is of night pain that is chronic and responsive to nonsteroidal antiinflammatory drugs (NSAIDs, eg, ibuprofen). Ewing sarcoma may rarely be seen in the calcaneus and may be difficult to distinguish from osteomyelitis. (See "Nonmalignant bone lesions in children and adolescents", section on 'Osteoid osteoma' and "Clinical presentation, staging, and prognostic factors of Ewing sarcoma" and "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Differential diagnosis'.)
INFECTIOUS, NEUROLOGIC, AND SYSTEMIC CAUSES — Cutaneous infections (cellulitis or abscess) involving the sole of the foot frequently follow disruption of the skin (eg, blister, puncture wound, or insect bite) or may arise from a retained foreign body such as a splinter, rock, or piece of glass. Extension of infection may cause an osteomyelitis. Plantar warts commonly occur on pressure points in the ball of the foot and the heel (picture 3). Enthesitis (inflammation of the sites where tendons or ligaments insert into the bone) at the insertion of the Achilles or plantar fascia on the calcaneus in the pediatric population should trigger clinicians to consider an inflammatory etiology. Reactive arthritis and rheumatologic disease are the two major considerations. Tarsal tunnel syndrome is caused by compression or inflammation of the tibial nerve.
Cellulitis and abscess — Cutaneous infections involving the heel frequently follow disruption of the skin (eg, heel blister, puncture wound, or insect bite) or may arise from a retained foreign body such as a splinter, rock, or piece of glass. Cellulitis involves infection of the epidermis, dermis, and subcutaneous fat and presents with redness, swelling, tenderness, and induration. Abscesses with pus collecting in the dermis and deeper layers may accompany cellulitis, especially when the infection is caused by methicillin-resistant Staphylococcus aureus or when there is a retained foreign body. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Skin abscess' and "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Cellulitis and erysipelas'.)
The diagnosis of a cellulitis or abscess is clinical. Further evaluation should include a radiograph to evaluate for an associated osteomyelitis, radiopaque foreign body, or gas gangrene. If a radiolucent foreign body is suspected, ultrasound may be useful. Cultures of blood or pus are typically not helpful in patients with mild infections but may be warranted in patients with systemic toxicity extensive skin involvement, underlying comorbidities (lymphedema, malignancy, neutropenia, immunodeficiency, splenectomy, diabetes), special exposures (animal bite, water-associated injury), or recurrent or persistent cellulitis. Cultures of swabs from intact skin are not helpful and should not be performed. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Cellulitis and erysipelas' and "Techniques for skin abscess drainage", section on 'Bedside ultrasonography'.)
The treatment of cellulitis and abscess is discussed separately. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis".)
Calcaneal osteomyelitis — Osteomyelitis in the calcaneus can cause heel pain often in association with a retained foreign body or puncture wound (eg, nail driven through a sneaker). Although the clinical presentation of osteomyelitis can be nonspecific, signs of infection (ie, fever, localized erythema, induration, swelling, and warmth and/or elevated erythrocyte sedimentation rate and C-reactive protein levels) may be present. (See "Hematogenous osteomyelitis in children: Clinical features and complications".)
The diagnosis of osteomyelitis is supported by a combination of (see "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Diagnostic approach'):
●Clinical features suggestive of bone infection (constitutional symptoms, focal symptoms and signs of bone inflammation, limitation of function, elevated white blood cell count, erythrocyte sedimentation rate and/or C-reactive protein) (see "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Clinical suspicion' and "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Blood tests')
●An imaging study with abnormalities characteristic of osteomyelitis (table 1) (see "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Radiographs' and "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Advanced imaging')
●A positive microbiologic or histopathologic specimen (eg, positive blood or bone culture) (see "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Microbiology' and "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Histopathology')
●A response to empiric antimicrobial therapy (see "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Response to empiric therapy')
Consultation with a pediatric orthopedic surgeon, infectious disease specialist, and radiologist is warranted when osteomyelitis is suspected to guide the diagnostic approach and treatment. The evaluation and treatment of osteomyelitis is discussed in detail separately. (See "Hematogenous osteomyelitis in children: Evaluation and diagnosis" and "Hematogenous osteomyelitis in children: Management".)
Plantar warts — Plantar warts commonly occur on pressure points in the heel and the ball of the foot. Overlying callus may cause pain. On inspection, plantar warts appear as hyperkeratotic papules that interrupt normal skin lines. They may also have tiny red or black dots within the lesion that represent thrombosed capillaries (picture 3). The differential diagnosis for plantar warts includes benign traumatic petechiae, called "black heel" or talon noir (picture 4 and picture 5), as well as melanoma, which are usually painless. (See "Dermoscopy of pigmented lesions of the palms and soles".)
The management of plantar warts is discussed separately. (See "Cutaneous warts (common, plantar, and flat warts)", section on 'Common warts and plantar warts'.)
Inflammatory enthesitis — Enthesitis at the insertion of the Achilles or plantar fascia on the calcaneus in the pediatric population should trigger clinicians to consider an inflammatory etiology. Reactive arthritis and rheumatologic disease are the two major considerations as follows:
●Reactive arthritis/enthesitis – Reactive arthritis/enthesitis typically presents with an asymmetric oligoarthritis, usually one to four weeks following infection with Escherichia coli; other enteric organisms such as Yersinia, Campylobacter, Salmonella, or Shigella species; or Chlamydia trachomatis. The extent of the interval between infection and the onset of arthritis considered consistent with a reactive arthritis by expert consensus is a minimum of several days and a maximum of several weeks. In at least half of patients, all symptoms resolve in less than six months; in most patients, symptoms resolve within one year. The several types of clinical manifestations of reactive arthritis include (see "Reactive arthritis", section on 'Clinical manifestations'):
•Symptoms of preceding enteric or genitourinary infection
•Musculoskeletal signs and symptoms
•Extraarticular signs and symptoms
Other than those symptoms due to the infection that has triggered the arthritis, the articular and extraarticular manifestations are similar regardless of the particular enteric or genitourinary organism or species of organism causing the disorder. The diagnosis of reactive arthritis is a clinical diagnosis based upon the pattern of findings. Evidence of antecedent or concomitant infection, elevated acute phase reactants (eg, erythrocyte sedimentation rate or C-reactive protein), positive testing for human leukocyte antigen (HLA)-B27, and imaging abnormalities are consistent with enthesitis or arthritis [31,32]. (See "Reactive arthritis", section on 'Laboratory and imaging findings' and "Reactive arthritis", section on 'Diagnosis'.)
The treatment of reactive arthritis is discussed separately. (See "Reactive arthritis", section on 'Treatment'.)
●Rheumatologic disease – Enthesitis-related arthritis commonly involves the plantar fascia and Achilles as well. The onset of rheumatologic disease in childhood often coincides with a period of increased sports activity in the second decade. Although the knee and the hip are the joints most commonly involved at the time of presentation, recurrent ankle or heel pain can also occur. Diagnosis of spondyloarthropathy may be delayed if complaints of pain are attributed to recurrent sprains or strains. The detection of painful tendon or ligament insertions (enthesitis) around additional joints is a prominent feature in approximately 75 percent of cases and is an important diagnostic finding [33]. Achilles tendinitis and plantar fasciitis are commonly identified. As an example, in one retrospective cohort of 32 children who were newly diagnosed with enthesitis-related arthritis, tenderness at the plantar fascial or Achilles tendon insertion of the calcaneus was described in 19 patients and was most frequently bilateral. (See "Spondyloarthritis in children" and "Oligoarticular juvenile idiopathic arthritis", section on 'Clinical presentation'.)
The diagnostic criteria for oligoarticular juvenile idiopathic arthritis and pediatric spondyloarthropathy are discussed separately. (See "Oligoarticular juvenile idiopathic arthritis", section on 'Diagnosis' and "Spondyloarthritis in children", section on 'Diagnosis'.)
Tarsal tunnel syndrome — The tarsal tunnel is a bony canal that runs below the medial malleolus and through which travel the posterior tibialis, flexor hallucis, and flexor digitorum tendons, posterior tibial artery and vein, and tibial nerve (figure 4). Tarsal tunnel syndrome will affect individuals with increased pressure in the tunnel or tension on the nerve. Pressure can be the result of improper foot orthosis or boot pressing on the tarsal tunnel, scar tissue from prior foot injury, as well as runners with inadequate hip stability in midstance will commonly hit the contralateral tarsal tunnel with the opposite shoe as it swings forward. Tension on the nerve occurs from excessive foot pronation. Injury to the tibial nerve causes neuropathic pain that typically radiates to the plantar surface of the forefoot (medial and lateral plantar branches) or the medial calcaneus (medial calcaneal branch). This is classic tarsal tunnel syndrome. Over time, compression of the tarsal tunnel can also result from injury of the posterior tibialis or flexor hallucis tendons. (See "Overview of lower extremity peripheral nerve syndromes", section on 'Tarsal tunnel syndrome'.)
Patients with tarsal tunnel syndrome typically present with aching, burning, numbness, and tingling involving the sole of the foot, the distal foot, the toes, and occasionally the heel. The pain may radiate up to the medial ankle. The discomfort is often most irritating at night, may be worse after standing, and sometimes leads to the desire to remove the shoes. The physical examination may be normal in patients with tarsal tunnel syndrome of relatively recent onset. Runners may have evidence of chronic abrasions on the posterior medial ankle. Other key findings include swelling below and posterior to the medial malleolus. Examination may disclose a prominent Tinel's sign (paresthesia when tapping over the nerve posterior to the medial malleolus) with sensory loss over the plantar surface of the foot, not extending onto the dorsal foot. Diagnosis may require nerve conduction studies in patients with equivocal clinical findings. (See "Overview of lower extremity peripheral nerve syndromes", section on 'Tarsal tunnel syndrome'.)
The treatment of tarsal tunnel syndrome is discussed separately. (See "Overview of lower extremity peripheral nerve syndromes".)
SUMMARY
●Anatomic approach – Heel pain in the young athlete can originate in the bones (fractures), apophyses, muscles and tendons (tendinitis), nerve, or fascia. Careful localization of the tenderness can help to narrow the differential diagnosis (figure 1). (See 'Evaluation' above.)
●Common acute injuries – Common acute heel injuries in children and young adolescents include friction blisters, open wounds, and contusions. Calcaneal fracture or Achilles tendon rupture is rare. (See 'Acute injuries' above.)
●Overuse conditions – Calcaneal apophysitis (Sever disease) is one of the most common overuse injuries causing heel pain in children and young adolescents. Other important causes include plantar fasciitis, painful heel pad syndrome (heel contusion), Achilles tendinitis, retrocalcaneal bursitis, and calcaneal stress fracture. (See 'Overuse injuries' above.)
●Bone conditions – Most bone conditions that cause heel pain are benign and include unicameral bone cysts and osteoid osteomas. Rarely, Ewing sarcoma may arise in the calcaneus. (See 'Bone conditions' above.)
●Infectious conditions – Cutaneous infections (cellulitis or abscess) involving the sole of the foot frequently follow disruption of the skin (eg, blister, puncture wound, or insect bite) or may arise from a retained foreign body such as a splinter, rock, or piece of glass. Extension of infection may cause an osteomyelitis. Plantar warts commonly occur on pressure points in the ball of the foot and the heel (picture 3).
●Inflammatory conditions – Enthesitis at the insertion of the Achilles or plantar fascia on the calcaneus in the pediatric population should trigger clinicians to consider an inflammatory etiology. Reactive arthritis and rheumatologic disease are the two major considerations. Tarsal tunnel syndrome is caused by compression or inflammation of the tibial nerve. (See 'Infectious, neurologic, and systemic causes' above.)
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