With the increasing participation of children in sports, clinicians are seeing more overuse injuries in this population. Using data from their experience, these authors review the treatment of overuse injuries such as Sever’s disease, navicular epiphysitis and secondary injuries with a focus on growth plate development.
There is a growing trend in the United States as parents continue to encourage their children to be more active in sports and after-school activities. Many kids play multiple sports after school in addition to activities at school. As children become more active and they physically begin to grow, they are more susceptible to injury.
When children wear shoes with inadequate support or athletes train hard, they are prone to overuse injuries. The foot and ankle are perhaps the most common locations for growth plate and overuse injuries in the adolescent patient.
When children present to the office of a foot and ankle specialist, they are often limping or are having trouble staying active due to the pain. The parents may complain about their children having trouble running when playing sports or keeping up with the other kids their age. If the child is between the ages of 4 and 16, then one must examine the growth plates of the foot and ankle closely. These injuries may occur secondary to trauma or from overuse in an active child.
We will prospectively analyze and discuss a preliminary study of 80 patients with growth plate injuries of the foot and ankle. The ages of the patients ranged from 4 to 15 years old. There were 51 patients with calcaneal apophysitis, eight with navicular epiphysitis, 10 with distal tibia epiphysitis, seven with fifth metatarsal epiphysitis and four with distal metatarsal epiphysitis. Most patients were active in sports including soccer, baseball, basketball, volleyball, running or tennis.
There were seven patients who developed symptoms after trauma, which was most common in younger children. These injuries occurred from jumping on a trampoline, falling from a height (such as gym equipment at the park or school), or bumping the foot at home on furniture.
Where Eversion And Resting Calcaneal Stance Position Come Into Play
Over the past three years, we have observed and documented the biomechanics of the foot in patients in the study, and we believe these biomechanics predispose many of these patients to overuse and growth plate injuries. When examining a child, we categorize the foot type into three stages: mild eversion, moderate eversion or severe eversion, which one determines by the resting calcaneal stance position (RCSP).
Stage 1 consists of mild RCSP of 0 to 4 degrees of eversion. Stage 2 is moderate RCSP of 5 to 9 degrees of eversion. Stage 3 involves severe RCSP of 10 degrees or greater. In our study, there were 34 patients with mild eversion, 42 with moderate eversion and four with severe eversion of the calcaneus in resting stance.
In our observations, we found that regardless of the location of the injury in the foot and ankle, patients with mild eversion often do not require the use of orthotics to help resolve their pain or prevent it from recurring. In contrast, in patients with moderate or severe eversion of the calcaneus, custom orthotics were not only an essential part of the treatment plan but vital in preventing recurrence in the growing adolescent.
How Growth Plate Development Affects The Clinical Picture
The bones of the foot and ankle develop skeletal maturity at different rates in each individual. In general, the bones of the foot and ankle begin to ossify by the age of 2 and fully mature by the age of 18. However, the epiphyses usually close two to three years earlier in girls than in boys. A plain X-ray is necessary to evaluate a possible growth plate injury. If one suspects an osteochondral or stress fracture, the use of a contralateral X-ray for comparison may be necessary.1
The practitioner may often be surprised to see an adolescent who is 16 years old with wide open growth plates on X-ray and sometimes a 13-year-old with completely closed growth plates. Each adolescent may mature differently, especially a competitive athlete. It is possible that the effects of overuse in a child athlete may expedite skeletal maturity. In our experience, the average appearance of centers for ossification of the epiphyses and closure of the epiphyses are earlier than prior reports by Tachdjian (see “A Quick Guide To The Epiphyses In The Foot And Ankle” at left).2,3
Recommended Treatment Protocols For Calcaneal Apophysitis (Sever’s Disease)
The most common growth plate injury in the pediatric patient population in our study was the calcaneus. The pain is usually located at the posterior and plantar aspect of the heel. There is often pain with lateral compression of the calcaneal body. Edema may or may not be present.4-6 Of the 51 patients in this study on calcaneal apophysitis, 44 calcaneal injuries occurred secondary to a sports injury or overuse and seven calcaneal injuries were secondary to trauma. Trauma included being kicked in a soccer game and falling off the gym set at the park. We assessed all patient pain scores on a scale from 0 to 10 with 10 being severe pain.
If a patient was limping or had a pain score of 4/10 or higher immobilization in either, we provided a below-knee controlled ankle motion (CAM) walker or fiberglass cast for two to six weeks. We recommend evaluating the patient every two weeks as this injury sometimes heals very quickly in the pediatric patient. If you are concerned about the patient minimizing weightbearing or not wearing the CAM walker at all times when weightbearing, the use of crutches and/or a fiberglass cast may be necessary to slow the patient down. If using a CAM walker, we recommend using a gel heel pad of ½-inch in height to assist with pressure relief (see photo at right). In addition, initial treatment should include oral anti-inflammatories such as Aleve bid with meals and ice bid to the affected area if the patient is using a CAM walker.
When a patient is limping due to Sever’s disease, he or she may develop a concomitant injury, which was common in 19 of our 51 patients. The most common secondary injuries included plantar fasciitis, Achilles tendonitis and peroneal tendonitis.
We also noticed that the maximal point of pain with palpation was often at the medial aspect of the calcaneus, which may be due to abnormal pronation in gait and an everted RCSP.9 In patients with moderate to severe RCSP, we recommend custom orthotics to help prevent recurrence and return to the child to shoes and sports.
We often recommend a deep heel cup of 18 mm and a 4 mm medial skive if there is an abnormal subtalar joint axis (see photo at left).7 We usually prescribe minimal cast fill for the pediatric patient to help improve the contour of the orthotic for maximal support.8 We recommend a topcover with Nylene or Spenco, and a heel pad with Poron. We typically invert the orthotic the same number of degrees as the calcaneal eversion (i.e. if the resting calcaneal stance position is 6 degrees of eversion, we will invert the orthotic 6 degrees). Controlling the abnormal pronation by exerting greater ground reactive force medial to the abnormal subtalar joint axis and rebalancing the calcaneus as close to perpendicular as possible will help minimize stress on the calcaneus.
If a patient is not limping and the pain score is 3/10 or less, we typically recommend gel heel pads and anti-inflammatories. Ice is an essential part of controlling the symptoms and preventing recurrence in the active adolescent.
Many of these patients will have mild calcaneal eversion. For these patients, gel heel pads or OTC orthotics may be necessary to help prevent recurrence once they return to shoes and sports.
What You Should Know About Navicular Epiphysitis (Kohler’s Disease)
There were eight patients in this study of navicular epiphysitis and all of them had an abnormal subtalar joint axis (too medially deviated). Seven of these patients had secondary posterior tibial tendonitis, which is secondary to abnormal pronation. All of these patients had moderate to severe calcaneal eversion.
Our treatment protocol included CAM walker immobilization with the use of an AirHeel ankle gauntlet (DJO Global) to minimize pronation. The ankle gauntlet is an alternative to tape strapping and will assist with minimizing pronation. It will help alleviate pain and tension on the posterior tibial tendon and navicular insertion. It will also be a good test to see if patients will tolerate additional arch support with a custom orthotic in the future as the support is primarily below the talonavicular and midtarsal joints. We also recommended ice and Aleve bid. Once the pain and inflammation had resolved after two to six weeks, we casted all of these patients for custom orthotics but they did not require surgery. All of the patients in this study did not have a recurrence once they received their custom orthotics.
Key Pearls On Treating Fifth Metatarsal Epiphysitis (Iselin’s Disease)
This injury may occur at the fifth metatarsal base or at the head of the fifth metatarsal depending on the skeletal maturity of the bone. Five of the seven patients with Iselin’s disease in this study developed fifth metatarsal pain after an ankle sprain. Peroneal tendonitis was common in four of these patients. We often misdiagnose this injury at the hospital or urgent care center as an open growth plate of the fifth metatarsal appears similar to a fracture (see right photo).
Treatment for this injury usually requires CAM walker immobilization with or without crutches. Ice and oral anti-inflammatories bid are necessary. Once the pain resolves, orthotics are not usually necessary. Since many of these patients have a concomitant ankle sprain, we recommend physical therapy including proprioceptive exercises to improve balance and strength, and help prevent recurrence.
Metatarsal epiphysitis of the first, second, third or fourth metatarsal (as well as the fifth metatarsal) was present in four patients in this study. This was a result of trauma in all four patients due to falling off a step or jumping and landing wrong. We recommended treatment in the same manner as the fifth metatarsal but once the pain had resolved, we would recommend a soft OTC orthotic or more supportive shoes. Physical therapy was not necessary for these patients.
Resolving Distal Tibia Epiphysitis
There were 10 patients in this study who had distal tibia growth plate pain. There were two patients who also had distal fibula pain in addition to the tibia inflammation. This injury occurred in six patients from repetitive jumping on a trampoline or cheerleading. Three of these patients developed secondary Achilles tendonitis. Eight of the 10 patients had moderate calcaneal eversion.
Based on our observations, we believe that distal tibia epiphysitis partially results from abnormal biomechanics. All 10 of these patients had an abnormal subtalar joint axis (too medially deviated), which may result in abnormal stress on the medial aspect of the ankle joint and inflammation of the growth plate with repetitive activities.
This injury requires complete non-weightbearing with crutches and a CAM walker or cast for two to six weeks. Ice and oral anti-inflammatories are necessary bid.
Once patients return to sports and activities, it is necessary to reduce ground reactive forces and minimize stress on the ankle. In patients with moderate to severe calcaneal eversion, we recommend a custom orthotic with a deep heel cup and inversion as necessary. We do not recommend a medial skive for these patients as it may make the heel too rigid. A soft topcover with a Poron heel pad will also help alleviate stress to the ankle joint.
When Patients Sustain Secondary Injuries
In this study, 36 of the 80 patients had a secondary foot injury. Typically when children develop a growth plate injury, they may not tell their parents initially and as they continue to stay active, they may develop a secondary injury from running or continuing to stay active. The pain may cause them to limp or the pain may wake them up at night, which often alerts the parents that there is a serious injury.
The most common secondary injuries in this study were plantar fasciitis, Achilles tendonitis and posterior tibial tendonitis. The use of a night splint was very helpful in patients with fasciitis and Achilles tendon injuries. We encourage the child to use the device when sleeping, watching TV, working on the computer or doing homework. It is not meant for weightbearing. The use of a topical anti inflammatory gel like 1% Voltaren gel (Novartis) can be very helpful for Achilles tendonitis if patients apply it two to three times a day. Typically, once the growth plate injury pain resolves and the adolescent starts walking and running normally, the secondary injury resolves on its own.
Overuse injuries in the adolescent patient are a growing epidemic in the United States as our children continue to be more active and competitive in sports and after school activities. When children complain of pain in the foot and ankle, it is very rare for them to have a stress fracture, osteochondral injury or neoplasm. Growth plate injuries should be at the top of the list in the foot specialist’s differential diagnoses.
In addition to understanding the biomechanics of the foot and ankle, podiatrists must evaluate the resting calcaneal stance position, its effects on ground reactive force and resulting stress on the bones and joints of the foot and ankle in order to determine the appropriate treatment plan.
The goal of the treating specialist should not only be resolving the pain but preventing recurrence of pain to the actively growing epiphyses until skeletal maturity. This is a challenge in the athletic adolescent but with advances in custom orthotics, improved and more supportive shoe gear and better awareness by foot and ankle specialists, we can help slow down this epidemic.
Dr. Feit is the President of Precision Foot and Ankle Centers. He is in private practice in Torrance and San Pedro, Calif.
Dr. Kashanian is in private practice in Los Angeles.
Mr. Feit is a research assistant at Precision Foot and Ankle Centers.
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8. Scherer PR. Recent Advances in Orthotic Therapy. Lower Extremity Review, Lexington, SC, 2011, pp. 82-84.
9. Becerro de Bengoa Vallejo R, Losa Iglesias ME, Rodríguez Sanz D, et al. Plantar pressures in children with and without Sever’s disease. J Am Podiatr Med Assoc. 2011; 101(1)17-24.
For further reading, see “How To Treat Overuse Injuries In Athletes” in the October 2007 issue of Podiatry Today.