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Foot Pain

Harry is a 12 year old boy with a 2 month history of pains in his heels - left more than the right. The pains are worse during and after sports. He has no night pain or joint pain elsewhere and is otherwise well. He is a keen sportsman and plays football, basketball and tennis but recently has had to stop half way through games. He can be stiff in the mornings and his heels are sore when he stands up out of bed. 

Otherwise he is fit and well and has had a recent growth spurt. His older brother has Juvenile Idiopathic Arthritis (JIA). He has been taking ibuprofen and paracetamol (acetaminophen) which are helpful. He has previously seen a physiotherapist and podiatrist but didn't like wearing the insoles as they were painful to wear. His mother is concerned that he may have JIA like his brother. 

On examination, he looks well but has mobile flat feet and tends to pronate when walking. He has a valgus hindfoot bilaterally. He is tender over his calcaneum on his left foot more than the right. 

This is likely mechanical foot pain as a result of his foot posture and hypermobility. 

However in view of the symptoms of morning stiffness and family history, inflammatory joint disease should be considered - he does not have evidence of arthritis or enthesitis (see pREMS - foot and ankle).

His tenderness is consistent with Sever's disease (osteochondritis of the heels). 

He does not have growing pains as he has daytime symptoms. 

If there are clinical concerns then referral to paediatric rheumatology is warranted. 

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