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X-rays for Children with Heel Pain

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Are X-rays Really Needed for Children with Heel Pain?

Many parents are concerned about exposing their children to radiation. Limiting dental and medical X-rays is one way to avoid overexposure to ionizing radiation (the kind of radiation that can do the most harm). But there are times when X-rays can help prevent worse problems. Heel pain and tenderness from Sever disease is one of those times.

According to this study from the children's hospital at the University of Tennessee in Memphis, there are enough abnormal findings on X-rays in children diagnosed with Sever disease that films should be routinely ordered.

Let's back up a bit and fill you in on the details. First of all, what is Sever disease (also known as Sever syndrome or by its medical term: calcaneal apophysitis)? Sever disease is a painful heel condition that affects growing adolescents between the ages of nine and 14.

In this condition, the growing part of the heel bone grows faster than the tendon that connects on the back of the heel. This tightens up the tendon and creates tension where it attaches to the heel. Eventually, the tension causes the area to become inflamed and painful. Fortunately, the condition is not serious. It is usually only temporary.

Heel pain is the main symptom. Squeezing the heel is painful. The back of the heel may appear red and swollen. It will probably be tender to the touch. The heel and foot may feel stiff, especially first thing in the morning. The heel tends to hurt during activity and feel better with rest. The calf muscles and Achilles tendon may also feel tight.

Youth who play running and jumping sports (especially on hard surfaces) are most prone to this problem. Sever disease or syndrome used to happen mostly in boys. But with more girls playing sports, boys and girls are now affected equally. Both heels hurt in more than half the cases.

Now back to the original question. Are X-rays really needed to make the diagnosis of Sever syndrome or disease? Actually, no -- but X-rays are advised for children with heel pain of unknown cause to rule out other problems like bone cysts, fibromas and other tumors, and fractures that can accompany Severe disease/syndrome.

In this study, they took a look back at the medical and radiographic records of 134 feet in children with a known diagnosis of Sever disease. They found a five per cent rate of other more serious problems along with Sever disease -- and these were problems that required additional treatment.

Without intervention, there could have been long-term consequences. So that's why the recommendation was made to continue the standard practice of ordering X-rays for children presenting with heel pain of unknown origin. The one difference is the type of X-rays. Only lateral radiographs (X-rays taken from the side of the foot) are needed. Limiting imaging to one view will reduce both the radiation exposure and the cost.

As a final note, the authors were unable to identify any particular factors that might help predict who would have just Sever disease versus those children with Sever and something else. Age, side of involvement, sex (male versus female), symptoms, duration or length of symptoms, and physical findings one examination did not reveal anything helpful in that respect.

In summary, it is possible to diagnose Sever disease or syndrome without X-rays just based on patient history, symptoms, and clinical exam. But to be sure something else more serious isn't going on, X-rays are required. And in this study, the number of children who did, indeed, have a second more serious problem was enough to say that the routine use of X-rays in any child with heel pain of unknown cause is still advised.

Reference: James N. Rachel, MD, et al. Is Radiographic Evaluation Necessary in Children With a Clinical Diagnosis of Calcaneal Apophysitis (Sever Disease)? In Journal of Pediatric Orthopaedics. July/August 2011. Vol. 31. No. 5. Pp. 548-550.

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