Posterior Heel Pain in Children

Posterior heel pain – discomfort felt at the back of the heel – is a relatively common issue experienced by active, growing children and adolescents. While often related to the stress of growth and activity, several different structures around the heel can be the source of pain. Understanding the potential causes and seeking an accurate diagnosis from a podiatrist in Singapore is key to effective management and keeping your child comfortable and active.

Children experiencing posterior heel pain may exhibit a range of symptoms, depending on the underlying cause:

• Pain and Tenderness: Localized soreness or aching at the back of the heel bone or slightly higher up along the Achilles tendon.
• Activity-Related Pain: Discomfort often increases during or after physical activities like running, jumping, or sports.
• Stiffness: Particularly in the morning or after periods of rest.
• Limping: Especially after intense activity.
• Swelling or Redness: Inflammation may cause visible swelling or redness around the painful area.
• Tenderness to Touch: The specific area of pain (e.g., heel bone growth plate, Achilles tendon insertion, bursa) is often tender when pressed.

Several conditions can cause pain at the back of the heel in children:

• Calcaneal Apophysitis (Sever’s Disease): The most common cause in children aged roughly 8-14. This involves inflammation of the growth plate at the back of the heel bone due to repetitive pulling stress from the Achilles tendon, especially during growth spurts and high activity levels.
• Achilles Tendinopathy/Tendonitis: Inflammation or irritation of the Achilles tendon itself, often near where it attaches to the heel bone. This is typically an overuse injury related to increased activity, tight calf muscles, or improper footwear.
• Retrocalcaneal Bursitis: Inflammation of the bursa (a small fluid-filled sac) located between the Achilles tendon and the heel bone. This can be caused by friction (e.g., from shoes rubbing) or repetitive stress.
• Insertional Achilles Tendinopathy: Pain specifically where the Achilles tendon attaches to the heel bone, sometimes associated with a bony prominence (Haglund’s deformity, though less common in young children).
• General Overuse/Training Errors: Rapid increases in the intensity, duration, or frequency of physical activity without adequate conditioning can overload the structures around the heel.
• Improper Footwear: Shoes that lack sufficient cushioning, support, or fit poorly can contribute to stress on the heel and Achilles tendon. Cleated shoes used in some sports can also play a role.
• Biomechanical Factors: Foot posture (like flat feet or high arches) or tight calf muscles can alter the forces acting on the heel and Achilles tendon, potentially increasing risk.

• Activity Limitation: Pain can significantly hinder a child's ability and willingness to participate in sports and physical education.
• Chronic Pain: If underlying issues like tendinopathy or bursitis are not managed effectively, the pain can become persistent.
• Altered Gait: Limping or changing walking/running patterns to avoid pain can potentially lead to compensatory issues elsewhere.
• Achilles Tendon Problems: Untreated tendinopathy could potentially worsen over time.

An accurate diagnosis by a podiatrist at Fine Podiatry Clinic is crucial to direct the correct treatment. This involves:

• Detailed History: Understanding the onset of pain, location, nature of symptoms, aggravating/easing factors, activity levels, footwear, growth history, and any previous injuries.
• Physical Examination:
  • Careful palpation (touching) to pinpoint the exact location of maximum tenderness (e.g., growth plate vs. tendon substance vs. bursa).
  • Assessing range of motion of the ankle and foot joints.
  • Testing calf muscle flexibility and strength.
  • Performing specific tests (like the heel squeeze test for Sever’s).
  • Evaluating foot posture and biomechanics.
  • Observing the child walking and potentially running.
• Imaging (If Needed): While often diagnosed clinically, imaging may be used to confirm diagnosis or rule out other issues:
  • X-rays: Can help assess bone structure, view the growth plate, and rule out fractures or bony prominences. Often normal in Sever’s or tendon issues.
  • Ultrasound: Effective for visualizing soft tissues like the Achilles tendon and bursae, identifying inflammation, thickening, or tears.
  • MRI: May be used in complex cases or if bone stress/other pathology is suspected.

Treatment is tailored to the specific diagnosis, severity, and individual child’s needs. The goal is to reduce pain, manage inflammation, address contributing factors, and facilitate a safe return to activity.

• Non-Surgical Treatments: Most causes of posterior heel pain in children respond well to conservative management:
  • Relative Rest / Activity Modification: Reducing participation in activities that significantly aggravate the pain is often necessary. This might mean temporarily switching to lower-impact activities or modifying training load.
  • Ice Application: Using cold packs after activity to reduce pain and inflammation.
  • Stretching Programs: Implementing regular, appropriate stretching exercises, particularly for the calf muscles (Gastrocnemius and Soleus) and hamstrings.
  • Strengthening Exercises: Guided exercises to strengthen calf muscles and other supporting muscles of the foot and ankle once pain allows.
  • Pain Relief: Use of simple analgesics like paracetamol or ibuprofen if needed for significant discomfort.
  • Footwear Assessment and Advice: Recommendations for supportive, cushioned shoes suitable for the child’s activities. Modifications to existing footwear might be suggested.
  • Heel Lifts or Padding: Temporary use of heel lifts or cushioned inserts can help reduce strain on the Achilles tendon and cushion the heel.
  • Custom Orthotics: May be considered if underlying biomechanical factors (like significant flat feet) are identified as a major contributor to the stress on the heel structures.
  • Taping or Strapping: Specific techniques can sometimes help support the foot or unload painful structures.
  • Immobilisation (Less Common): In some severe or persistent cases (e.g., severe Sever’s, significant tendinopathy), a walking boot may be used for a short period to enforce rest.
• Surgical Options: Surgery is rarely required for the common causes of posterior heel pain in children and adolescents. It might only be considered in very specific circumstances for chronic conditions (like resistant retrocalcaneal bursitis or certain tendon issues) that have failed extensive conservative management, typically in older adolescents or adults.

Note: Our podiatrists will develop a personalised management plan based on the accurate diagnosis of your child’s heel pain.

Helping prevent overuse injuries around the heel involves:

• Proper Warm-ups: Ensuring children warm up adequately before sports and activities.
• Regular Stretching: Maintaining good flexibility, especially in the calf muscles.
• Appropriate Footwear: Using well-fitting, supportive, and activity-appropriate shoes. Replacing worn-out shoes promptly.
• Gradual Increase in Activity: Avoiding sudden spikes in training volume, intensity, or frequency. Allow the body to adapt gradually.
• Listen to the Body: Teaching children to recognise and report pain early, rather than pushing through significant discomfort.
• Vary Activities: Encouraging participation in a range of activities (cross-training) can reduce repetitive strain on specific areas.