BILATERAL HEEL PAIN IN AN ADOLESCENT RUNNER

Abstract

HISTORY 15 year old cross country runner complaining of bilateral heel pain, right greater than left, for three weeks shortly after the onset of the season. He denies any trauma or specific injury. He denies any night pain or paresthesias. He reports the pain primarily on the medial and lateral sides of the heel bilaterally. He does report some morning stiffness and increased heel pain going down stairs. PHYSICAL EXAMINATION His gait is normal. There is pes planus bilaterally. There are no skin changes. There is some retrocalcaneal area tenderness bilaterally. There is no heel cord tenderness although there is mild associated tightness of the Achilles tendon bilaterally. There is pain with side to side calcaneal compression in both extremities. The origin of the plantar fascia is nontender and there is no plantar surface tenderness. There is no ankle instability and manual muscle testing is slightly diminished throughout. There is no neurovascular deficiency. DIFFERENTIAL DIAGNOSIS Calcaneal apophysitis. Calcaneal stress fracture. Retrocalcaneal bursitis. Tarsal tunnel syndrome. Pathologic fracture through a bone cyst. Plantar Fasciitis. Heel pad syndrome. TEST RESULTS Bilateral foot and ankle radiographs:–A/P, lateral and axial views without obvious osseous abnormality and essentially closed physes. Bilateral foot and ankle MRI:– There is a calcaneonavicular coalition in both feet. In addition, there is extensive bone marrow edema within each calcaneus and osseous changes consistent with stress fracture. There is also abnormal thickening of the ATF and CF ligaments and intermediate signal within the flexor hallucis longus tendon suggestive of chronic injury. FINAL/WORKING DIAGNOSIS Bilateral calcaneal stress fractures with underlying tarsal coalition and chronic tendonopathy. TREATMENT AND OUTCOMES Nonweightbearing with crutches and immobilization in a low tide walker boot for the right (more symptomatic) side for 4 weeks. Subsequent ankle rehabilitation. Return to sport when there is normal strength, ROM and resolution of pain with strenuous activity. If symptoms persist beyond this time or recur, consideration will be given to surgical correction of the underlying tarsal coalitions.