Heel pain in kids. What are we missing?

Fascinating thing, Sever's Disease. Why do some kids suffer from it? Why do some sail through rapid periods of growth without so much as an ache when other kids are crippled with pain?

I have a theory….

It has long been understood that Sever’s is a condition of growing. The most commonly affected age group is 8-12 year olds, with boys being slightly more affected than girls. The assumption is that there is an asymmetry in the growing rates of the bones of the lower leg and the muscles, which causes a pulling, or traction on the growth plate at the back of the heel bone. The growth plate is soft and does not fully harden until after puberty. Sever’s causes heel pain, and is often seen in very active children who have had rapid periods of growth, but not always. All kids grow, so why isn’t everyone affected. And why do some kids display other growth related conditions such as Osgood – Schlatters disease which affects the knee?

I think we are missing something. I think growing is only one side of the coin.

“the likelihood of the event immediately preceeding your pain being the true underlying cause is virtually zero”

Perry Nickelston

In my experience, this is often true (except in the case of true accidents obviously). Our bodies have an innate ability to keep us functional, to keep us on our feet and moving forward. So in the presence of a biomechanical issue, be it bone structure, joint structure, muscle weakness or imbalance, or following an injury, the body will find a way to just keep moving. A bit like a river when rocks fall in and block the flow of water. The river needs to keep flowing, so the water will find another way downstream. The body too, will find another way.

Traditionally, treatment for Sever’s involves rest from aggravating activities, sometimes orthotics, padding in the shoes and a stretching regime. It is said to be self-limiting, ie: it will resolve of it’s own accord within 6-12 months. But what if there is something else going on in a child’s posture that predisposes them to this pain in their heels? This seems to be a question that is rarely asked.

Last week I had a delightful young boy come into the clinic who had been suffering, and I mean suffering from Sever’s type pain for 12 months. It was significantly impacting his life. A very sporty kid, he was still participating in all his activities but often left the sporting field in tears. He looked so sad when we were talking about his pain, and his poor mum told me what I already knew, that is was so difficult to see her son like this.

He had been seen by a physio who had prescribed the standard treatment protocol but despite diligence on the boy’s part he was still in crippling pain. So he’d been referred to me by his GP.

His foot assessment wasn’t particularly remarkable. He had tight calves, which is very common in kids with Severs. Standing was a different story. All his weight was in his right leg, and that foot had a high arch while the left arch was flat. His pelvis and head were rotated to the right and his trunk to the left. His right shoulder was dropped. He looked awkward and uncomfortable. It’s often difficult to know what came first; the posture resulting in the pain or vice versa. I enquired about other injuries. The only other one immediately preceeded the Sever’s. A left groin strain that lasted for 6 months. Very unusual for a young child. But interesting considering his posture. With a shifted pelvis, the opposite groin muscle can become locked long, as it desperately tries to stop the weight moving further away. If you stretch a rubber band for too long, eventually it fatigues. Same principle. This muscle was most likely overworking, hence the pain. What else is overworking I thought. Running through my head was the question WHY? Why are the calves tight? What benefit does that provide for the body? It is a strategy to maintain function?

I use a technique called Neuro Kinetic Therapy (NKT – google it. It’s facscinating). It test the neurological connection between the brain and the muscles. Sometimes muscle pairs get into bad relationships, where one takes over the work of another. Eventually, the overworking muscle throws it’s hands in the air and say ‘I’m done’, and symptoms result.

So I tested my theory using NKT protocol and found that one of the calf muscles (the gastrocnemius) of the right leg was overworking for one of the quadriceps. The calf muscle is strong but it ain’t that strong. So in this case, the theory of the calf muscle pulling on the soft growth centre stands up, but the reason of why the muscle was pulling so hard only came to light by using NKT and asking WHY. Without identifying the reason for the calf muscle being tight, you could stretch it until the cows come home, but you are never actually addressing the true issue. That's why the stretching regime he has previously undertaken had not stopped the pain. It was only one side of the coin.

We reset the pairing and went through the homework that he would need to do multiple times a day. I chose to complement this with some gait based, dynamic exercises to address the postural changes. He took to these a duck to water. The light had certainly returned to my young clients face. We discussed sport and we agreed that his Mum and I could trust him to stop voluntarily if he were in pain. I know he will do his exercises. He’s motivated, not only to get out of pain but also to get back to doing what he loves. I look forward to seeing how he is going in a fortnight.

There’s a huge lesson in this case for me.

Look deeper.

Think critically.

Ask why.

Why is the pain there, especially in a young body? Are we being to simplistic in blaming growth? I think sometimes it’s easier to assume rather than to ask these questions.  I think growth is only one side of this particular coin.

Could Sever’s be the result of an overactive calf working for an underactive quad, or glut in the vast majority of children who suffer from it. I think so. 

It makes far more sense to me that this is the true cause of the pain, and that the site of the pain is merely the vulnerable part, the weak link in the chain.

In our profession we have a term to describe results of joint ranges of motion or muscle strength. WNL – Within Normal Limits. But one of my lecturers at uni once said to me “ What is really stands for is We Never Looked” That has always stuck with me. As a practitioner, you want to make sure that’s not how you operate.

Always ask WHY.