HEEL PAIN IN CHILDREN
Sever’s is most common in 9 - 12 year olds. It’s sore to squeeze the bone at the base of the Achilles where it attaches onto the heel. It’s not something that can be seen - it never seems to look red or swollen. It’s worse after sprinting, jumping, and hopping. It settles with rest. It is an overuse injury so it’s common in pre-season, or anytime training loads increase too quickly. My kids get it when they do extra sessions in running spikes or footy boots, without the normal heel support of their running shoes. It’s an overuse injury from excessive loads.
When we talk about excessive loads it can be “external” load such as:
I think the running pace is the more powerful multiplier in this list. Extra sprint sessions will do it. My kids got sore once when we did a boot-camp session with a novel plyometric exercise - split jumps.
There are also “internal” variables that determine our ability to cope with the training load:
My kids definitely are more prone to Sever’s if they’ve had a couple of late nights that week. And, if they’re having a growth spurt, their bodies are busy spending resources on growing rather than recovering from the stress of a training session.
Text books say that Sever’s disease is self-limiting because the growth plate eventually fuses by the age of 15 or 16. But I don’t think there’s anyone who would be happy to just let it run its course until then. It is usually sore enough to stop you participating in sport, so it needs treatment.
WHAT DO WE DO?
I used to put kids with heel pain in orthotics, until I read this research which confirms that a simple heel wedge is more effective than orthotics for Sever’s disease. Cheaper and easier.
I get them to do an isometric Achilles strengthening program which also helps with pain control.
But ultimately recovery comes down to load management.
Load management means reducing the excessive loads. So this could be:
And aid recovery with:
HAVE YOU HAD A CHILD WITH SEVER’S DISEASE?
I’d guess that most people feel guilty about not stretching enough.
Interestingly, health professionals have changed our tune about the importance of stretching. Research over the last 15 years has suggested static stretching is not as beneficial as was once thought. I’ve been having conversations about the reasons to stretch (or not) for at least the last 10 years, but the current science on stretching just isn’t catching on.
So, what do we know?…
DOES STRETCHING PREVENT INJURIES?
No. There is a lot of evidence that stretching does not reduce the risk of injury. This systematic review and meta-analysis of randomised controlled trials found stretching does not prevent injuries, whether done before or after training. This randomised controlled trial, and this systematic review concluded stretching before exercising only reduces the risk of injury by less than 1%.
Therefore, in practical terms the average athlete would need to stretch for 23 years to prevent one injury. Definitely not worth it.
DOES STRETCHING HELP MUSCLE SORENESS?
No. A systematic review concluded that stretching before or after exercising does not confer protection from muscle soreness (ref). Stretching was found to reduce muscle soreness by a trivially small amount - less than 2%.
“Most athletes will consider effects of this magnitude too small to make stretching to prevent later muscle soreness worthwhile.”
DOES STRETCHING INCREASE RANGE OF MOVEMENT?
No. Stretching for the amount of time that most people would hold their stretches, does not make any actual difference to flexibility. The mechanisms of stretching have been extensively studied. There is moderate evidence from a systematic review that stretching can increase flexibility (ref). However, to achieve an actual improvement in muscle compliance we know the total duration of stretching needs to be at least five minutes per muscle group (ref). Therefore to stretch hamstrings, quads, and calves, both left and right, as part of a warm up before sport, it should take at least 30 minutes - which is practically impossible as part of a warm up. We know the one or two, thirty second stretches the majority of athletes would perform during their warm up are just not enough to actually improve their flexibility (ref).
DOES STRETCHING HELP PERFORMANCE?
What people find most surprising about static stretching is it impairs subsequent performance (ref).
A substantial body of research has shown that sustained static stretching acutely decreases muscle strength and power (ref). Stretching before an endurance event lowers endurance performance and increases the energy cost of running (ref). Cycling efficiency and time to exhaustion are reduced after static stretching (ref).
Pretty much any measure of performance is made worse by stretching. Static stretching impairs:
A comprehensive review (ref) from 2011 concludes:
“Based on the majority of the literature, it would seem logical to recommend that prolonged static stretching not be performed prior to a high level or competitive athletic or training performance.”
WHAT ABOUT DYNAMIC STRETCHING?
Obviously, I’ve been talking about sustained, static stretching. It has been shown that there is no stretch-induced strength loss with dynamic stretching (ref). However, the efficacy of dynamic stretching for increasing flexibility is yet to be determined (ref).
SO WHY STRETCH?
I do get people to stretch if there’s a specific pathology that needs treating. And you do need to stretch if you need flexibility to achieve certain positions in your sporting performance (hurdlers / gymnasts / divers, etc).
SO SHOULD WE STOP STRETCHING?
If you’re happy with your stretching routine, keep doing it. If you think it feels good to stretch after exercise then there’s no harm. But I definitely wouldn’t recommend stretching at the expense of other techniques that are proven to aid recovery.
Do you love a good stretch?
I’ve been frustrated this week by a couple of patients with Achilles problems that I thought should recover well. They’ve disappeared to go and have an injection, against my recommendation. It’s made me think about whether or not I should have made the referral myself? What are our options for injections, and do they work?
There are a range of commonly prescribed treatment options for tendinopathy, but very few are supported by quality, randomised, prospective, placebo-controlled trials.
SO WHAT DO I DO?
WHAT ABOUT INJECTIONS?
There are a range of drugs to inject into or around a tendon, depending on who you are referred to:
- Corticosteroid (A strong anti-inflammatory)
- Prolotherapy (An irritant to stimulate new tissue growth, e.g. hypertonic dextrose/glucose)
- Sclerotherapy (An irritant to decrease vascularisation, e.g. Polidocanol)
- Traumeel (A homeopathic preparation derived from arnica)
- Actovegin (derived from calf blood)
- Autologous blood (injecting your own blood into the tendon to promote healing)
- Platelet-rich plasma (blood is taken and PRP is extracted and injected to promote healing)
- High-volume injections (to damage the tissue and encourage new growth)
PROLOTHERAPY / SCLEROTHERAPY
AUTOLOGOUS BLOOD INJECTIONS
PLATELET RICH PLASMA (PRP)
WHY DO THE INJECTIONS WORK FOR SOME PEOPLE?
REGRESSION TO THE MEAN
Injections are a powerful way to administer a placebo effect. You need to see a specialist to receive it. You need to pay more money. There’s some high-tech equipment spinning the blood. Everything is set up for you to expect improvement and, in a decent percentage of cases, that’s all it takes to get better. If you believe the injection will help you then it is much more likely to work. However, the research tells us it doesn’t really matter what substance is injected, it is your belief in whether or not it will help that is the variable more likely to determine the outcome.
Have you had an injection for your tendon?