I have just seen the 8 year old child with Traction Apophysitis featured in previous posts. Since January 26, when I first saw him, he has followed a strict programme of reduced activity.
He has been fantastic in wearing trainers at school – remember that all the other children are barefoot – and severely limiting or stopping any activity that caused pain. Although, about a month ago we did let him start swinging a golf club at the driving range!
His mother reports that he no longer sits on the side of the bed in the morning rubbing his painful feet. Has no pain after school, even though he has recently started playing some soccer at break time and he is completely pain-free.
Today's X-rays show a normal appearance of the calcaneal epiphysis (the growth area/point at the back of the heel), and improved bone density.
The plan now is to slowly start activity again and that will be rugby.(He plays barefoot). The trainers must still be worn as often as possible. Follow up will be in 6 months.
The diagnosis of Traction Apophysitis is usually based on the presenting clinical symptoms, as the X-ray findings are often inconclusive. Nevertheless we must never ignore the younger child with painful heels and always consider Traction Apophysitis.
Management is clearly "rest", by reducing or avoiding those activities that cause pain. A supportive but soft/cushioning trainer is the best footwear. There is a place for short term anti-inflammatories followed preferably by topical gels and plasters.
Whatever we try, there is always the question of 'what would have happened if we had done nothing?" I believe that that decision can only be made with the individual patient in front of you, so that you can respond with clinical judgement and personal empathy. However there is no doubt that for many children it is a transient condition.
My apologies for not getting the case history on the site as promised.
THE COMPLETE CASE HISTORY WILL BE ON THE WEBSITE SOON.
Never ignore foot pain. A recent case of tibialis posterior tendon rupture is a case in point.
A 76 year old lady was brought to me by her daughter because she could barely walk and was in constant pain. She had been prescribed anti-inflammatories and sleeping tablets for 'the arthritis.'
At her only previous visit to me in 2003, I had diagnosd the potential for flat foot related problems and made orthotics. The lady never kept any follow up appointments.
This time, the lady described her symptoms as "the left foot is giving me hell. Over the past year, it's been getting gradually worse and now I can't wear my shoes."
When I asked about the previous treatment, she informed me that she gave up with orthotics because they didn't fit easily into her shoes.
When I examined the foot, it was completely flat and rolled over and the arch was non-existent. The lady was unable to stand for more than a few seconds and she couldn't manage more than two steps across the room. In addition she was unable to raise up onto tiptoe.
As I traced a path along the inside of the foot up behind her ankle to the lower part of her calf she experienced significant pain. This is the path of the Posterior Tibial Tendon, the main tendon to help form and hold the arch of the foot.
Posterior Tibial Tendon
I immediately sent the lady for X-rays and an Ultrasound scan. The scan revealed a rupture of the Posterior Tibial Tendon.
Referral for surgery has been completed and now we wait for the outcome, except that she has developed a problem with her eyes that needs treating before any surgery can take place.
The moral of this story? Follow up is vital from both sides of the medical equation. Ignoring foot pain can have serious consequences, so managing it is a team effort.
READ THE FULL CASE HISTORY IN Case Histories
I'll be back again as a guest expert on Talk Radio 702 & 567 Cape Talk on Tuesday Feb 17.
The programme is called 'A Word on Medical Matters' anchored by Leigh Bennie with host Prof. Harry Seftel and is broadcast starting from 19.00 -20.30.
It's a live phone-in, plus replies to text massages and emails so this is your opportunity to get the latest current advice if you have any pressing problems.
Here's some feedback on the boy with the traction apophysitis. Did you think the overuse was extreme? What did you think of the training routine?
Firstly, he has wonderful parents! They have followed my advice to wear shoes and avoid all activities that cause stretching of the Achilles tendon. Secondly,they have been surfing the Internet to find out more about the condition. They showed the youngster pictures and explained the reasons why he has to take it easy. This means that he understands that time spent recovering now will enable him to participate again when the condition settles. Thirdly, they have stopped all sport at school.
Fourthly and this is the best bit. His father tells me that he asked his son to rate the pain. If the pain was rated as a 10 when he saw the podiatrist what is the rating today? About 2 or 3 says the boy.
In our sports mad country its refreshing to get such team work going.
At this stage it is imposible to say how long healing will take, but the initial response of the foot to simple rest and supportive footwear is encouraging. Rehabilitation will be very important; in the form of stretching very carefully, accompanied by orthotics or simple insoles.
Traction apophysitis does heal and all the better it seems with lots of TLC (Tender Loving Care).
Keep looking for the full case history – its nearly finished
P.S. Tune in to Talk Radio 702 17 February 19.00
