Kenneth Meisler, DPM, PLLC, DABPS Associate Director, Division of Podiatry Director of Podiatric Medical Education Beth Israel Medical Center New York, NY Private Practice 210 East 86th Street New York, New York 10024 [email protected]

Dr. Meisler graduated from NYCPM in 1974. He is Board Certified in Foot Surgery and Board Certified in Podiatric Orthopedics and Primary Podiatric Medicine. He is a fellow of the American Academy of Podiatric Sports Medicine. He was the co-chief of the division of Podiatry at New York Downtown Hospital, which had NYCPM residents for more than 25 years. He is the director of Podiatric Medical Education at Beth Israel Medical Center in New York. Beth Israel has just finished the first year of their own PM&S 36 program. The podiatry residents have joined more than 400 residents and fellows currently at Beth Israel.

Dr. Meisler is a former marathon runner and treated thousands of athletes while the podiatrist of The Preventive and Sports Medicine Center in New York City along with it's medical director Norbert Sander, M.D., former winner of the NYC Marathon.

Dr. Meisler has always been very interested in imaging and is a consultant in digital imaging for 20/20 Imaging, LLC and will be presenting a series of interesting case studies that include digital images, MRI's, ultrasounds etc. He will also be helping Present Learning develop a library of digital images that residents and podiatrists can use for lectures or in their offices.

Calcanial apophysitis, described by Sever in 1912, is a traction apophysitis of the Achilles tendon at its calcaneal insertion. In half of the cases it is bilateral and the child is often between 10-12 (boys) or 8-10 (girls). It is seldom a presenting complaint in those above 15, as this is most often the time at which growth centers within the calcaneus have fused.²

Possible differential diagnosis’ include:

Achilles tendonitis, retro-calcaneal bursitis, tibialis posterior and peroneal tendinitis (usually at ages 15 -17), juvenile rheumatoid arthritis seen at age 6 - 14, tumors (unicameral bone cyst, osteoid osteoma, Ewing’s sarcoma), trauma (calcanial, talar, navicular and cuboid fractures), tarsal stress fractures( these are rare, around 2% of all stress fractures in children and  are most common in skeletally maturing patients participating in intensive sports training), tarsal  coalition and bone infection.²

Ribbans et al. state that foot fractures in the child may pose diagnostic challenges, especially when there are no obvious radiographic changes at first glance. They also advocate the judicious use of MRI and bone scans to aid diagnosis in this setting.

In a prospective study of 61 children with a diagnosis of calcanial apophysitis, Kose¹ questioned the need for x-ray imaging in making a diagnosis of calcaneal apophysitis. In his evaluation of 70 x-rays of children with non-specific heel pain, he found that in only one case did x-rays change the diagnosis from calcaneal apophysitis to a simple bone cyst.   X-rays should, therefore, not be used to make the diagnosis of calcaneal apophysitis, but to aid in excluding others.²

Children are often difficult to get a direct history from. For that reason, using ancillary testing in the diagnostic process can be of great help.

When children of the appropriate age present with posterior heel pain that is aggravated by activity, and does not have a history of an acute injury other than repetitive trauma, the first diagnosis that physicians consider is Calcaneal Apophysitis. However it is important to be aware of the other conditions that can cause similar symptoms. 

The following cases presented to my office within the past 6 months.

CASE 1:

A 14 y/o male patient presented to our office with a chief complaint of bilateral heel pain. His past medical history was unremarkable, except for a previous left calcaneal fracture in 2006 due to a mogul skiing incident, that was plated and healed uneventfully (see figures 1 and 2).

He related a history of gradual onset in pain, starting after a lacrosse training trip that entailed a lot of running and subsequent bilateral heel pain. A week after his return, he was practicing on a turf field and developed pain in the right heel that was felt while walking. After playing two days with the pain, he could not play any longer and took two days off. Upon his return, the pain was still present and he could only complete half of the practice. Pain was present on palpation of the posterior heel and body of the calcaneus bilaterally.  Careful evaluation revealed the body of the calcaneus to be more painful than the posterior aspect/apophysis.

X-rays where taken (figure 1 and 2) that were inconclusive. However, a tentative diagnosis of possible bilateral calcaneal stress fractures was made.  The patient was referred for an MRI of the right foot, because it was more symptomatic and an MRI of the left foot would be difficult because of artifacts caused by the plates and screws.  The MRI (figure 3) shows an obvious dorsal calcaneal stress fracture (arrow). The patient was placed in a CAM-walker and given a bone stimulator.  The left foot was treated by rest only.  The patient healed uneventfully.

Figure 1

Figure 2

Figure 3

CASE 2:

A 14 y/o male presented to our office with a chief complaint of heel pain in the left foot. His past medical history was unremarkable and he had been experiencing left heel pain for around 6 months.  He is an avid participant in multiple sports and recalls the pain starting about two days after a sporting practice, which increased gradually.  He had continued participating by limiting the number of practices and times he participated each week.  On examination, there was pain on palpation of the plantar and posterior heel. However, a palpable mass was also noted within the plantar fat pad under the heel and when questioning the patient, he stated that was the area of most discomfort.   X-rays (figure 4) did not show any obvious fractures or pathology that could account for his discomfort.  A comparison was taken of the opposite asymptomatic foot and it appeared similar. An Ultrasound (figure 5) was performed in our office and a hypoechoic area of tissue within the plantar heel was noted. The patient was sent for an MRI (figure 6) that revealed an ill-defined area of soft tissue thickening along the medial aspect of the left heel fat pad.
 
The differential diagnosis’ included: Foreign body granuloma or area of fat necrosis.  The patient has had relief from dispersion padding and is being followed.

Figure 4

Figure 5a

Figure 5b

Figure 6

The goal of this presentation is to make physicians aware that when a child presents with posterior heel pain, a careful history and examination may reveal it is not always calcaneal apophyysitis.

References:

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