Calcaneal apophysitis: Simple diagnosis, simpler treatment

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Applied Evidence

Calcaneal apophysitis: Simple diagnosis, simpler treatment

J Fam Pract. 2007 May;56(5):352-355

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References

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4. Ishikawa SN. Conditions of the calcaneus in skeletally immature patients. Foot Ankle Clin N Am 2005;10:503-513.

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10. Contompasis JP. The management of heel pain in the athlete. Clin Podiatr Med Surg 1986;3:705-711.

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Patients typically have no swelling, skin changes, erythema, or other local abnormalities.⁸ The most characteristic distinguishing feature on physical examination is exquisite pain produced on medial and lateral compression (“squeezing”) of the heel at the site where the calcaneal apophysis attaches to the main body of the os calcis. The pain is not on plantar pressure (as you would see with plantar fasciitis), or posterior, retrocalcaneal, or adjacent to the Achilles tendon (as you would see on Achilles tendinitis), but on medial and lateral compression.³

227 cases: Trends I’ve seen in my practice

I’ve noticed a number of trends over the years while caring for patients with calcaneal apophysitis. My chart review of the 227 patients I cared for between 1971 and 1997 revealed the following:

60% (137) of patients had bilateral involvement.
78% of the patients were male. The reason for the male preponderance remains unclear.
All but 3 of the 364 feet obtained eventual complete symptom resolution with the prescribed sponge-leather heel orthotic.
Symptoms typically resolved within 60 days.
The 3 cases that were recalcitrant to orthotic treatment required an equinus-type cast for 4 to 6 weeks. Those patients treated with a cast also had resolution of their symptoms.
Roughly 30% of the cases encountered a recurrence of symptoms with similar resolution with the previously described retreatment. Recurrences were unrelated to gender.
No case ever required any other treatment type beyond the orthotic or cast.—Dennis Weiner, MD

Researchers found microfractures. Magnetic resonance imaging (MRI) evidence suggests that the true pathogenesis of calcaneal apophysitis is a stress microfracture related to chronic repetitive microtrauma.⁹ In addition, MRI evidence suggests that the location of the stress microfractures is in the metaphysis of the body of the calcaneus adjacent to—but not directly involving—the apophysis.^1,7 This more recent evidence replaces the historical hypotheses that the condition is primarily an inflammatory process. As a consequence of the microtrauma, however, it’s possible that an inflammatory process may occur secondarily.

FAST TRACK

Restricting physical activity is not necessary with use of the shoe orthotic

Should you order x-rays? X-rays are not essential to the diagnosis, though they may be used to rule out other conditions, such as fracture, infection, or a bone cyst. Keep in mind, though, that patients with calcaneal pain will have a normal x-ray.⁷ What is normal, however, is another matter, and has been the subject of confusion in the past.

Pain stops in a few weeks

Usually, the symptoms of calcaneal apophysitis resolve fairly quickly, and with relatively simple treatment. (The symptoms also disappear as the child gets older and the calcaneal apophysis amalgamates with the main body of the calcaneus.)

Physiotherapy, forced ankle dorsiflexion stretching, gastrocsoleus stretching, ice, heat, heel cups and pads,^1,10-13 and anti-inflammatories have all been used in the management of the condition.^3,8 Clinicians have also historically restricted the patients’ activity, but this is unnecessary.

Rx for relief: ⅝″ compression orthotic

An in-shoe soft orthotic is helpful in treating calcaneal apophysitis. The prescription that the lead author writes is for a ⅝″ compressible, sponge-filled leather orthotic that is made in the form of a heel wedge or heel pad. Pain relief is believed to occur as a result of relaxation of the tension on the gastrocsoleus complex inserting onto the calcaneal apophysis and by “cushioning” the impact of heel strike.³ The orthotic, which typically lasts for 3 to 6 months, generally abrogates the need for anti-inflammatories as a primary treatment. However, relief of discomfort during this period may include use of antiflammatories.

For many years, the lead author has utilized a simple in-shoe, wedge-shaped orthotic consisting of a sponge material covered by leather, and compressible down to ⅝″. It raises the heel and cushions the impact of weightbearing. It can be transferred from shoe to shoe, and the patient can resume full activities while wearing the orthotic. Pain relief is generally achieved within 6 weeks to 3 months. Recalcitrant cases may require a 4 to 6 week period of casting in a plantar flexed position. Surgery is not necessary, nor are there any surgical cases reported in the literature. Orthopaedic referral is indicated for recalcitrant cases.

Acknowledgments

The Audio-Visual Department, Children’s Hospital Medical Center, Akron and Adeline Weiner assisted in preparing this paper.

Correspondence
Dennis S. Weiner, MD, 300 Locust Street, Suite 160, Akron, OH 44302-1821. mdicintio@chmca.org