Ankle pain in a teenager

ID: 13 y/o healthy ♂ with gradual onset of Rt ankle pain 2/52 ago; now limping; not able to fully weight bear on the Rt foot; 

HPI: dull aching pain with activity; no pain at rest; no radiation; pain has gotten worse over the past 2 wk; no recent injury; Hx of mild remote injury 2mo ago while ice skating, did not seek medical advice at that time and the pain resolved completely after a few days, with no pain in the interim; no similar Sx in other joints; no previous similar episodes; involved in competitive ice skating; skipped a few ice skating practice sessions; ⊘fever/chills; ⊘B-Sx; ⊘blurred vision; ⊘GI Sx; ⊘am stiffness; 

PMH: non contributory

E/O: looks well, NAD, VSSA

Rt lower limb: 
Hip and knee joints unremarkable with full ROM.
Ankle: ⊘swelling, ⊘erythema, ⊘skin ▵s, ⊘atrophy, symmetrical compared to the Lt ankle; limited, painful dorsiflexion, ROM otherwise Ⓝ; post. heel area tender to touch; no plantar tenderness; unable to stand on tiptoe due to sever pain; pes planus; neuromuscular unremarkable;  

I/P: Rt heel pain due to Sever’s disease; RICE; reduction of athletic activities; NSAIDs prn; gradual increase of activity when pain better to a pain tolerance level; good quality shoes; vesicoelastic heel caps; f/u if pain refractory to conservative management; 

Discussion(1): 

Sever’s disease (calcaneal apophysitis) is the foot equivalent of Osgood-Schlatter disease; a traction over use syndrome; not an inflammatory condition (apophysitis is a misnomer); pain can be so sever that pt needs to use crutches; 

A cause of late childhood, early adolescent heel pain; most often between the ages of 8 and 13 yr; bilateral in ≈60%; 

Usually pt is involved in sports that need a lot of running (esp. on hard surfaces with low heeled shoes) & jumping; 

Dx is clinical; X-ray is not necessary; medial/lateral compression causes pain in the pos 3rd of the heel; sever pain with standing of tiptoe (Sever sign); Pain on foot dorsiflexion; X-ray if Dx is in question or refractory to conservative Rx (may indicate calcaneal stress # which needs immobilization 3-4wk); 

DDx may include: 

1. calcaneal bursitis
2. Achilles tendinitis
3. plantar fasciitis
4. calcaneal stress #

Rx is conservative if no response ➜ short leg cast or walker boot (duration? probably determined by the severity of the Sx); good quality shoes with adequate shock absorption and firm heel counter; ⊘ long-term sequelae; time to resolution variable, but complete resolution with skeletal maturity; 

Reference: 

1. https://itunes.apple.com/ca/app/5-minute-sports-medicine-consult/id445352494?mt=8