Common Overuse Injuries of the Pediatric Lower Extremity

Authors: Calvin Hwang, MD, Stanford/Kaiser Emergency Medicine, Residency Program, Stanford, CA.

Leroy Sims, MD, Clinical Instructor, Orthopedic Surgery, Clinical Instructor, Surgery — Emergency Medicine, Sports Medicine Center, Stanford University, Stanford, CA.

N. Ewen Wang, MD, Associate Professor of Surgery, Associate Director, Pediatric Emergency Medicine, Stanford University School of Medicine, Stanford, CA.

Peer Reviewer: John Cheng, MD, Assistant Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.

Musculoskeletal and connective tissue complaints are the third most common chief complaint in the emergency department (ED), comprising nearly 20% of all ED visits.1 While the diagnosis and management of acute injuries are well delineated in the emergency medicine literature, pain from lower extremity overuse injuries is less commonly addressed.

Although chronic injuries can be frequently dealt with on an outpatient basis by primary care physicians, they often present to the ED because of 24/7 availability and an inability to obtain urgent primary care physician appointments. This article serves as an overview in the etiology, presentation, diagnosis, and initial management of chronic pain of the pediatric lower extremity. More acute injuries, such as non-stress-related fractures and ligamentous injuries of the knee, will not be covered here.

— The Editor

Etiology of Overuse Injuries

More than 35 million children ages 5 to 18 years old in the United States participate in organized sports; this, coupled with increasing single sport specialization at young ages, has resulted in increasing numbers of patients with overuse injuries presenting to both the emergency department and primary care offices.2 Children, particularly those who have not yet reached skeletal maturity, are at particular risk for a unique constellation of overuse injuries. In fact, boys ages 5 to 14 years old comprise the highest percentage of visits to the ED for sports-related injuries.2 Pediatric overuse injuries can be broken down into three common categories: apophysitis, tendinitis, and stress fractures.

Skeletally immature athletes are at particular risk for sustaining injuries at the apophysis (the point where the muscle tendons insert into the bone), as this is the weakest part of the muscle-tendon-bone complex. With athletic activity, there is a pulling of the tendon from the bone at its insertion, leading to micro-avulsions.2 Although these microavulsions would typically heal on their own, as athletes compete at a younger age with shorter periods of rest, the repetitive micro-injury and inflammation develops into apophysitis.3,4 These injuries are more common during periods of rapid growth and are normally self-limited as patients reach skeletal maturity and the ossification center fuses. Apophysitises of the lower extremity, each of which will be further described below, are most frequently found in the heel (Sever’s disease), knee (Osgood-Schlatter disease), and pelvis.5 Tendinitis, while generally less frequent in the pediatric population due to the relative weakness of the apophysis, is most commonly seen in the patella and peroneal tendons. It is a result of direct injury or trauma to the tendon or tendon sheath.4 Stress fractures are the result of repeated forceful impact and loading stresses on immature bone.4 As the amount of trauma exceeds the ability of physiologic repair, pain from microfractures develops, which worsens with activity and improves with rest. These injuries occur most commonly in the tibia, calcaneus, and navicular bones.

A number of risk factors have been identified in the development of apophysitis and other injuries causing overuse injuries. (See Table 1.)

Table 1. Common Associations Between Patient Characteristics and Pediatric Overuse Injuries

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General Approach

Common overuse injuries will be discussed by system using the following general approach:

Pertinent History. A careful, detailed history is critical in diagnosing overuse injuries. Information such as timing of onset of symptoms relative to exercise, improvement (or lack thereof) with rest or other exacerbating activities is important, as it will help distinguish between many of the diseases affecting a particular area. The age of the patient and whether he or she has reached skeletal maturity also plays an important role in the diagnostic algorithm, as apophysitis is less likely when the physes are closed on X-ray.

Exam. A complete exam of the affected area, as well as the joints above and below, are mandatory in the evaluation of the patient. In addition to palpation, thorough passive, active, and resisted range-of-motion testing is particularly useful, as it can further define the particular muscle or muscle group responsible for the patient’s symptoms.

Diagnostic Tests. Radiographs are strongly recommended in all patients presenting to the ED with chronic lower extremity pain. Although many of these overuse injuries are made by clinical diagnosis, it is important to exclude fracture or other pathology. Keep in mind that some injuries, such as fractures of the navicular bone or stress fractures, may not show up on initial X-rays. High-risk areas like the navicular bone may warrant a CT in the ED and/or close outpatient follow-up for possible MRI.

Management. Although there may be occasional instances when immobilization or protected weight bearing are needed in the treatment of specific overuse disorders, the mainstay of treatment for all overuse injuries involves reduction of the exacerbating activity, application of ice, targeted stretching or compression, and anti-inflammatory medication (similar to the frequently used treatment acronym RICE — rest, ice, compression, elevation). A course of standard, weight-based dosing of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (Tylenol) can be safely used to treat pain in overuse injuries and will not impair the healing process. Patients can generally return to their regular activities when their pain has resolved. These injuries are largely self-limiting, given the natural resolution of these overuse injuries, particularly apophysitis, as the child becomes skeletally mature. Nevertheless, it can be reassuring to both the patient and family to have a diagnosis and an understanding of the natural history and prognosis for these injuries.

Overuse Injuries by System

Hip/Pelvis. Hip and pelvis pain can be particularly difficult to diagnose, as non-athletic-related injuries of the hip can lead to chronic pain when the patient exercises. Although not true overuse injuries, slipped capital femoral epiphysis (SCFE) and idiopathic osteonecrosis of the capital epiphysis (Legg-Calvé-Perthes disease, LCP) can both cause chronic hip and groin pain with athletic activity.

Patients with SCFE present with decreased internal rotation of the hip. These patients often keep the affected limb in a position of comfort, externally rotated and flexed. They also frequently complain of medial knee pain and may have no complaint of resting hip pain at presentation, but have pain with manipulation of the hip. On pelvis X-ray, there is a widening of the femoral physis on the frontal view; slippage of the femoral epiphysis can be best visualized on a frog-leg lateral view. (See Figure 1.) SCFE requires prompt orthopedic referral, as surgical intervention is often needed.

Figure 1. X-ray Demonstrating SCFE

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LCP is the result of idiopathic disruption of the vascular supply to the femoral head, leading to eventual collapse of the femoral head due to bone resorption. Children, most often boys ages 4 to 8 years with delayed skeletal maturity, may initially present with a painless limp that gradually worsens as the femoral head collapses. Similar to those patients with SCFE, children affected by LCP disease also have pain or difficulty with internal rotation of the hip. Although LCP often affects younger patients than SCFE, a radiograph of the hip is necessary to diagnose this condition and will demonstrate widening of the hip joint coupled with flattening and irregularity of the femoral head. (See Figure 2.) This is also found in patients with avascular necrosis as a result of sickle cell disease.

Figure 2. X-ray Demonstrating LCP

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SCFE tends to occur in older adolescents nearing or at puberty (ages 10 to 16 years), while LCP most commonly affects children ages 4 to 8 years of age.4 Both disease processes require imaging of the hips for diagnosis, although X-rays may be negative early in the course of LCP. Close follow-up is crucial for patients with either disease entity, and orthopedic consultation should be made in the ED for possible urgent operative fixation.

Multiple large muscle groups in the leg attach to the hip. (See Figure 3.) With frequent contraction of these muscle groups in the growing athlete, this can lead to apophysitis in a number of areas of the pelvis. The muscle attachments most often affected are the anterior superior iliac spine with the sartorious, the ischial tuberosity with the hamstrings and adductors, the iliac crest with the iliopsoas and gluteal muscles, and the anterior inferior iliac spine with the rectus femoris.3,4 These patients present with pain isolated to the affected region of the hip, which worsens with use of these muscles. Patients who have an acute onset of pain may have an avulsion fracture from a sudden eccentric contraction of the muscle. The mainstay of treatment for patients with apophysitis is reduction of activities that exacerbate symptoms and scheduled doses of anti-inflammatory medications, while those with a clinical picture concerning for an avulsion fracture should receive orthopedic consultation and follow-up. As symptoms improve over the course of four to six weeks, the patient may begin to increase his or her exercise activity as tolerated.

Figure 3. Major Muscle Origins and Insertions of the Pelvis and Proximal Femur

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Some athletes, particularly runners, may present with an audible snap or snapping sensation in their hip, usually either the medial or lateral hip, with running or walking. Anteromedial snapping of the hip is often caused by subluxation of the iliofemoral ligament over the femoral head or the long head of biceps femoris over the ischial tuberosity.4 Laterally, this sensation represents the rubbing and subluxation of the tensor fascia lata/iliotibial (IT) band over the greater trochanter of the femur.6 (See Figure 4.) While these patients may initially be pain-free despite the snapping sensation, they can subsequently develop bursitis of the iliopsoas and the greater trochanter, leading to pain and decreased exercise tolerance. The mainstay of treatment for these patients is again rest and NSAIDs.

Figure 4. Cross Section of the Femoral Head and Greater Trochanter

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Knee. Chronic knee pain is the most common musculoskeletal complaint in the adolescent athlete, occurring in up to 40% of females and 30% of males.6 The differential for this pain is broad, but can be categorized largely by location of pain in the knee and the age of the patient. (See Table 2.) With all pediatric patients complaining of knee pain, care must be taken to perform a comprehensive hip exam in order to ensure that the pain is not referred from the hip, as can occur in SCFE and LCP. As described above, pain from these two entities is often referred to the medial knee.

Table 2. Most Common Locations of Knee Pain by Diagnosis

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Chronic knee pain most commonly presents with anterior pain. Traction apophysitis of the distal pole of the patella (Sinding-Larsen-Johansson [SLJ] disease or jumper’s knee) is a disease that tends to affect pre-teen boys more often than girls.7 (See Figure 5.) Caused by persistent, repetitive, and forceful traction of the immature inferior patellar pole leading to abnormal calcification and ossification of the inferior patella, patients with this disease complain of pain on the inferior aspect of their patella and patellar tendon.4 These patients will complain of worsening pain when jumping and kneeling. Radiographically, these patients will sometimes show fragmentation or irregular calcification of the inferior patellar pole, but a radiograph often is negative.3 Treatment is conservative, consisting of rest from the exacerbating activity until pain resolves, ice, anti-inflammatory medications, and knee bracing for comfort (RICE). In the skeletally mature patient, this same presentation is due to patellar tendinitis, and the treatment is the same. Although typically self-limiting, patients with traction apophysitis of the distal pole of the patella who continue to participate in exacerbating activities, on rare occasion, can develop necrotic intratendinous tissue, warranting orthopedic consultation. Patients with continued or worsened pain despite conservative treatment should be referred to a sports medicine specialist for examination and possible MRI imaging, which may demonstrate soft-tissue necrosis.

Figure 5. Sinding-Larsen-Johansson Disease

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Patients in their early teenage years with chronic anterior knee pain typically have traction apophysitis of the tibial tubercle (Osgood-Schlatter disease, OSD). OSD is due to traction, similar to that in jumper’s knee, on the tibial tuberosity and physis by forceful contraction of the quadriceps.4 Patients who participate in sports involving running or jumping are at increased risk for both OSD and SLJ disease. The condition is present in up to 20% of athletes and occurs bilaterally in 20-30% of those affected.7 Patients complain of tenderness directly over the tibial tubercle and pain with activities requiring forceful extension, such as jumping, climbing stairs, and rising from a squatting position. X-rays often show an ossicle formation, or calcification of an avulsed fragment of the tibial tuberosity,3 (see Figure 7) but play a limited role in determining duration of treatment. The treatment regimen is the same as for Sinding-Larsen-Johansson disease.

Figure 7. Ossicle Formation Over the Tibial Tuberosity

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In patients nearing or at skeletal maturity (often around the time of menarche in female athletes and the early teenage years in males), patellofemoral pain syndrome (PFPS) is the leading cause of chronic anterior knee pain. These patients, more commonly female, present with an insidious onset of pain without any acute injury or mechanical symptoms suggestive of meniscal injury.2 They complain of pain during and after physical activity, after prolonged sitting (the so-called movie theater sign), crepitus, and stiffness.8 On exam, these patients can have tenderness to palpation of the medial patellofemoral ligament or peripatellar area, but may have no pain on exam. Key findings on exam are quadriceps atrophy, particularly of the vastus medialis obliquus (VMO) (see Figure 6) and abnormal lateral shifting of the patella in extension (J sign).8 Radiographically, X-rays typically show a skeletally mature patient and occasionally an abnormal patellar tilt on a sunrise view.9 Treatment is based on quadriceps strengthening with physical therapy, particularly of the VMO, to help promote medial stabilization of the patella. In fact, studies have shown that physical therapy is a required element in reducing patellofemoral pain.10

Figure 6. Right Medial Quadriceps Atrophy

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Chronic lateral knee pain is most frequently caused by iliotibial (IT) band syndrome. The IT band extends from the tensor fascia lata and proximal knee flexors to its insertion on the lateral aspect of the proximal tibia. During physiological flexion and extension of the knee, the IT band passes over the lateral condyle of the femur. Inflammation can develop in the IT band, causing pain with this snapping movement, particularly with high stepping and climbing or descending stairs.4 On exam, the patient may have lateral joint line tenderness corresponding to the inflamed IT band. Ober’s test can be helpful in diagnosis if positive.7 To perform an Ober’s test, the patient is laid on his or her side with the affected hip up. The patient’s affected hip is then extended and adducted. If the patient’s knee on the affected extremity cannot touch the exam table or has pain in doing so, Ober’s test is positive. Treatment for IT band syndrome is rest, ice, compression, and anti-inflammatory medications (RICE).

Chronic medial knee pain, in addition to referred pain from the hip, is also often caused by osteochondritis dissecans (OCD) of the knee. Caused by a disorder of ossification in the femoral subchondral bone, OCD most often occurs on the lateral aspect of the medial femoral condyle.11 This defect in ossification, in conjunction with repetitive axial loading and microtrauma from physical activity to the injury-susceptible immature articular cartilage, leads to the breakdown of the overlying articular cartilage and fragmentation of cartilage and bone.5,12 Three times more common in males and most often occurring in pre-teens and teenage athletes, patients with OCD lesions complain of poorly localized medial knee pain that worsens with exercise and climbing hills or stairs. They may also have some tenderness along the anteromedial joint line of the affected knee. Radiographic findings include a cystic-appearing lesion in the femoral condyle. The finding can be seen on any view, but MRI is the gold standard. There is some variation in the literature regarding treatment, but conservative non-surgical treatment is successful more than 90% of the time and generally consists of protected partial weight-bearing for 4-6 weeks, followed by a period of activity modification.5 Surgical management of these lesions includes drilling and stabilization versus excision.

Ankle. Chronic ankle pain in a child is unique in comparison to hip or knee pain in that it is less likely to be caused by an apophysitis, but rather is caused by a multitude of possible sources throughout the joint. As with acute ankle injuries, ligamentous injuries, if not adequately treated, can lead to chronic ankle pain. However, as these patients often have an acute event leading to chronic pain, they will not be discussed here.

Anterior ankle and shin pain, often referred to as shin splints, can actually be caused by several unique disease processes. A common complaint, shin splints are the cause of 60% of all exercise-related leg pain, frequently presenting as a tightness in the anterior tibia.7 Shin splints can be caused by medial tibial stress syndrome or chronic exertional compartment syndrome. If left untreated, they can result in tibial stress fractures. They are typically the result of a significant increase in exercise intensity and/or duration over as little as a couple of weeks. Shin splints commonly present with diffuse pain over the anterior tibia, worsened by ankle dorsiflexion and plantarflexion. When caused by inflammation of the tibialis anterior and other ankle dorsiflexors, patients complain of pain with forced contraction of the dorsiflexors and passive plantarflexion.11 In medial tibial stress syndrome (MTSS), overuse of the soleus through repeated forceful pronation and plantar flexion of the foot, as in sports involving running or sudden changes in direction, leads to inflammation at the attachment at the tibia along the posteromedial aspect of the tibia.4 These patients complain of a deep, dull pain that can be difficult to distinguish from tibial stress fractures.4 In either case, these patients have normal X-rays and are managed with rest, NSAIDs, and stretching with a gradual return to play when pain decreases.

Two more serious causes of chronic anterior ankle/shin pain are tibial stress fractures and chronic compartment syndrome. The tibia is the most common site of pediatric stress fractures. These patients present with point tenderness over the affected area of bone, which helps distinguish stress fractures from MTSS.11 A high index of suspicion for tibial stress fractures must be maintained in patients presenting with chronic tibial pain. They may have normal X-rays if symptoms have been ongoing for less than 14 days, and management of these patients is very different from management of MTSS. A trial of activity modification can be attempted, but if pain persists, these patients should be placed in a short leg cast for 4-6 weeks and may return to play two weeks after pain resolves.11 Patients who are ultimately diagnosed with tibial stress fractures should be screened for eating disorders, which make patients more susceptible to stress fractures.

In chronic compartment syndrome, patients present with exercise-induced pain in the anterior tibia as a result of inflammation of the muscles leading to elevated compartmental pressures. These patients have no pain at rest, but often have a highly predictable onset of pain after exercising for a fixed amount of time or running a particular distance.7 On exam, their anterior tibial compartment is tender and firm or bulging during and immediately after exercise. These patients can also have decreased ankle dorsiflexion and anesthesia in the first dorsal webspace.11 Activity modification can help reduce symptoms, but for high-level athletes or those with persistent symptoms and a good history, referral to an orthopedic specialist should be made, as surgical interventions, such as fasciotomy in some cases, can be performed after confirmatory testing via MRI or measuring compartment pressures.11

In addition to chronic tears of any of the three lateral ankle ligaments, chronic lateral ankle pain is commonly caused by the peroneal tendon. In peroneal tendinitis, patients present with lateral ankle swelling and pain posterior to the fibula, in addition to ankle instability. This entity is caused by overuse of the peroneal tendon, which is particularly susceptible to inflammation because of its tethering around the lateral malleolus.13 Resisted eversion reproduces this pain on exam. Although X-rays are often normal in patients with peroneal tendinitis, they should be obtained to exclude fractures or other possible causes of pain. Rest, ice, and NSAIDs should be tried, but patients with severe symptoms or who fail initial management should have a trial of ankle immobilization.13 Patients with peroneal tendon subluxation present with similar ankle swelling and pain, but also complain of a popping sound or sensation in their posterior ankle as the peroneal tendon subluxes over the lateral malleolus. Although uncommon, this is usually the result of an acute subluxation leading to recurrent subluxation and instability.13 On exam, these patients have a palpable and sometimes visual subluxation of the peroneal tendons with forced foot dorsiflexion and resisted eversion. Symptomatic patients should be referred to orthopedic surgery for possible surgical correction.13

In a similar mechanism as described for the knee, osteochondritis dissecans (OCD) can also affect the ankle, leading to chronic pain. OCD lesions in symptomatic patients most often present with pain in the anterolateral aspect of the ankle. These patients have occasional stiffness and instability in the joint and have increased pain with inversion or tibial-talar compression on exam.13 When compared to OCD lesions in the knee, patients with ankle lesions have X-ray findings less frequently. While initial treatment is non-surgical with immobilization and limited weight-bearing, patients should be referred to orthopedics for possible surgical debridement of the lesions.

Foot. While foot and heel pain is uncommon in the pediatric population compared to adults,14 the incidence of foot and heel overuse injuries is increasing in correlation with the increase in participation in organized sports.15 The many bones of the foot, and the direct impact on these structures during most sporting activities, make them particularly susceptible to overuse injuries.

Iselin’s disease is a traction apophysitis of the base of the fifth metatarsal, causing lateral foot pain with weight-bearing. (See Figure 8.) Caused by running, cutting, and inversion stresses, repetitive microtrauma to the apophysis leads to local swelling and tenderness.11 Pain can be elicited on exam with resisted eversion and extreme plantar flexion. Radiographically, these injuries can be confused with fractures at the base of the fifth metatarsal (dancer’s fractures), but can be delineated by noting the preservation of the metatarsal-cuboid joint.16 Treatment is conservative with rest, stretching of the evertors and plantar flexors, and strengthening of the opposing invertors and dorsiflexors. As with other apophysitis, the disease process is often self-limiting, as fusion occurs with skeletal maturity.

Figure 8. Iselin’s Disease

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Similar to occult scaphoid fractures in the wrist, injuries to the navicular bone of the ankle are important to diagnose due to the risk of avascular necrosis (AVN). In a navicular stress fracture, patients present with an insidious onset of pain over the medial and/or dorsal midfoot, which worsens with exercise and sometimes continues into the early resting period. On exam, they have tenderness to direct palpation of the navicular bone. This physical finding is more sensitive than X-ray for a stress fracture.14 As a result, patients with negative X-rays but a high index of suspicion for a stress fracture should undergo CT. Due to decreased vascularity of the middle third of the navicular, these injuries are particularly susceptible to AVN and require a non-weight-bearing cast for at least six weeks as well as possible surgical referral for non-union.16 Although generally acceptable for most chronic overuse injuries, NSAIDs should be avoided in the treatment of high-risk fractures like those of the navicular bone.17

Another common cause of chronic midfoot pain, os navicularis or accessory navicular bone, occurs in 2-12% of all patients.18 Located at the insertion of the posterior tibialis muscle, the accessory navicular can cause pain in some patients as the bone ossifies with skeletal maturity. These patients have pain and tenderness to palpation on the medial border of the navicular and may have a palpable accessory ossicle. X-rays are important, as the presence of the ossicle helps distinguish this condition from navicular stress fractures. Passive stretching or resisted contraction of the posterior tibialis muscle through forced eversion or resisted inversion can also reproduce the pain and aid in diagnosis. Management is conservative with activity modification and padding over the navicular bone.

Another cause of midfoot pain and involving the navicular bone, Kohler’s disease, or osteochondrosis of the tarsal navicular, occurs when the blood supply to a portion of the navicular bone is disrupted by trauma or overuse, leading to collapse of the cartilage and bone. This occurs most frequently between the ages of 5 and 9 years old, and these children present with midfoot pain that is worsened with weight-bearing, sometimes causing a limp.13 As with navicular stress fractures, patients have tenderness to palpation over the navicular. However, X-rays will demonstrate sclerosis and narrowing of the tarsal navicular, helping to distinguish this condition from both os navicularis and acute or stress fractures of the navicular.16 These patients have an excellent prognosis and are treated conservatively with rest, ice, and anti-inflammatory medications, as the navicular will regain its normal shape as the foot matures.

Tarsal coalition is the fusion of two or more tarsal bones via a bony or fibrocartilaginous bridge. Most commonly involving the calcaneonavicular or talocalcaneal joints and present in an estimated 1-2% of the overall population, patients with tarsal coalitions present with tenderness to palpation at the subtalar joint, limited subtalar motion, and pain with foot inversion.13 Although they are generally congenital, tarsal coalitions do not cause pain until ossification occurs when the patient reaches adolescence. X-rays can be helpful in diagnosing calcaneonavicular coalitions, but talocalcaneal coalitions may be more difficult to visualize. CT is the gold standard for diagnosing and evaluating all tarsal coalitions. Initial treatment is stretching, strengthening, and increasing joint proprioception, but refractory pain may require surgery.

Chronic forefoot pain, particularly in adolescent female dancers, is commonly caused by osteonecrosis of the metatarsal head, or Freiberg’s infraction. Generally occurring in the second or third metatarsal head, Freiberg’s infraction is caused by repetitive trauma to the forefoot, leading to collapse and sclerosis of the articular surface of the metatarsal head.13 These findings can be seen on X-ray, in addition to widening of the metatarsal joint. Patients complain of a gradual onset of pain in the forefoot that worsens with weight-bearing and activity. Treatment is rest and immobilization, but may require prolonged casting if pain is acute or persistent. Nevertheless, the disease is typically self-limiting, as reossification occurs in 2-3 years.13

The most common cause of heel pain, calcaneal apophysitis or Sever’s disease, is caused by inflammation to the calcaneal growth plate as a result of overuse of the ankle plantar flexors. Patients with Sever’s disease, more commonly boys than girls, aged 8-14 years, note a recent increase in training or competition and complain of a dull ache in the posterior and plantar aspects of their heel after prolonged activity or initial resumption of activity after rest.16 They have tenderness to palpation with medial and lateral compression of the calcaneus, which is considered pathognomonic for the disease.16 X-rays can sometimes show fragmentation of the apophysis, but MRI is the gold standard for diagnosis and can be obtained on an outpatient basis if it is considered to be clinically warranted by the patient’s pediatrician.14 These patients should be managed with rest, NSAIDs, shoe cups with properly fitting athletic footwear, and stretching of the plantar flexors and plantar fascia.

Heel pain can also be caused by a calcaneal stress fracture. Often related to repetitive microtrauma, calcaneal stress fractures occur at the calcaneal metaphysis. Children playing baseball/softball or football are at increased risk due to the use of cleats that add increased pressure directly below the heel. X-rays have poor sensitivity in diagnosing these patients, and an MRI is often needed.14 In addition to activity modification, these patients should be referred to an orthopedic or podiatry specialist for possible cast immobilization if symptoms do not improve.

In contrast to the pain of calcaneal apophysitis and also affecting those who have reached skeletal maturity, patients with plantar fasciitis complain of inferior heel pain that occurs with the initiation of exercise or first thing in the morning, which improves after increased activity. Caused by microtrauma to the plantar aponeurosis from jumping or prolonged standing, plantar fasciitis occurs in 10% of runners and presents with tenderness to palpation on the anteromedial aspect of the heel, particularly with dorsiflexion.7 The inflammation causes muscle spasm and splinting of the plantar fascia, which is the source of the patient’s pain.4 Although X-rays are not needed to diagnose plantar fasciitis, they can be useful in excluding other disease processes. Treatment is supportive with relative rest, ice, massage, arch support, stretching of the fascia and heel cord, and anti-inflammatory medications.14

Conclusion

The incidence of overuse injuries has increased as participation in organized sports has increased. The unique nature of the muscle-bone-tendon complex and the plasticity of skeletally immature bone predispose the pediatric athlete to a particular set of injuries not seen in the adult population. Although there are a large number of disease processes as described in this article, the majority of these injuries are self-limited and will resolve with skeletal maturity of the patient. This information will allow for general reassurance of patients and their families. General initial management, aside from the few exceptions discussed previously, consists of rest from exacerbating activities, ice, anti-inflammatory medication, and targeted stretching. We must also be able to do a proper initial work-up of these injuries and determine which patients need additional imaging, close follow-up with their pediatrician, and/or referral to an orthopedic specialist.

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