Learn about Growth Plate Injury

Casey Bass: There is something going on with my shoe, my heel keeps killing me, I have no idea what's going on. But, I walk around on my toes all the time, I am tall enough. I don't need to be any taller. So today, we are going to see Dr. Marshall to see if we can get this taken care of. Luckily enough we're joined once again by friend of the show, Director of Sports Medicine at Children's Healthcare of Atlanta, David Marshall and his son Grant(ph). Guys, thanks for joining us. David Marshall: Thanks for having us. Casey Bass: Today, we move on to Sever disease. What is Sever disease? Is it man after Tom Sever? David Marshall: No, unfortunately it's spelled a little different. This is Sever's disease or Sever's condition named after Dr. Sever. I believe way back about 50-60 years ago, and what Dr. Sever did is he figured out that there is a growth plate in the back of the heel called the Calcaneus. And that growth plate serves as an anchor point for the calf muscle and Achilles tendon and in young kids between the ages of 7 and 12 that pre-adolescent age, that growth plate is very active and if they happen to play a sport involving a lot of running or jumping, then through repetitive pulling and traction on that calf muscle and Achilles tendon, they get little tiny microscopic cracks in that growth plate. Casey Bass: We've heard a lot about growth plate injuries, and it's obviously something you deal with a lot. Why don't you show us where those particular growth plate is. David Marshall: Yeah, down here in the calcaneus which is another name for the heel bone, I think that the calcaneus is being shaped like half of a tennis ball. If you take a tennis ball and slice it in half, and take half of the ball and cup it over the heel, that's the growth plate. So these kids really can have pain anywhere from the very top of the heel all the way down to the under side, on the inside, and it can even grow all the way around to the outside. Most of the kids that I see have most of their pain on the inside of the heel right around where I have these blue stripes, and it's because when you run and jump and play sports, you typically plant and cut and you put a lot more pressure on the inside of your heel more so than the outside. Another contributing factor is flat feet. A lot of the kids that I see that have Sever's condition pronate, or when they stand up, their arches collapse a little bit and that just puts a little more pressure on the inside edge of that growth plate. Casey Bass: You said that flat feet were a problem, that you think we need to talk about more. Would you mind coming back in a later day, and we could actually sit down and talk about, something that a lot of people talk about is flat feet. David Marshall: Right. I think the feet tend to be the most neglected joint in the sports. All through often, kids come in complaining of shin pain, knee pain, even hip pain and lower back pain. If you don't take their shoes and socks off and look and see where the rubber hits road, and neglect that, then it's just like you are trying to drive your car with flat tires. You are not going to perform like you should. So I'd be more happy to come back and talk about remedies for flat feet. Casey Bass: Stay tuned for the flat feet episode with the two pad foot, me and Dr. Marshall. So let's talk about some of the symptoms of Sever's disease. David Marshall: The first symptom is pain. After the kids come in from the workout or playing or a contest, they will complain of pain in the heel, and they are very well able to localize it. They won't point to the Achilles tendon, they won't point to their arch, they will put their thumb or their finger around the back of that heel. A lot of times because it's the heel that hurts during that heel strike phase of walking or just putting that heel on the ground during walking and running, is painful for them. So a lot of these kids that have Sever's condition will actually walk on their toes. They will try to be on their tip-toes to avoid putting that painful heel on the ground. Casey Bass: So what causes this? What makes a kid end up walking on his toes? David Marshall: It's one of those growth plate conditions, remember like the ones we have talked about before. If a muscle or a tendon attaches to a vulnerable weaker growth plate, it's the growth plate that fails and in Sever's condition, the culprit is the calf muscle and Achilles tendon, as that muscle on Achilles comes down, it tends to fan out as it grabs onto that cartilage growth plate in the heel. So running and jumping, and basically just moving, pulls on that calf muscle which pulls on the growth plate, and it's a growth plate that gets injured. Casey Bass: Now, you told me that Grant actually had Sever's and you attributed part of it to his flat feet. Could you expand on that a little bit? David Marshall: Yeah. When you think of the configuration of the growth plate, I think the growth plate in the heel is like half of a tennis ball. So if you take a tennis ball, and slice it in half, and cup it over the heel, you can see that the growth plate not only is in the back of the heel, but also on the inside and the outside. If you think of a kid that pronates or that has collapsing of their arches and look at them from behind, their Achilles tendons do this, they're kind of banana or bow inward because their weight is going to the inside. So just by the fact that their weight is putting more pressure on the inside of the heel and then when they run, cut, play sports, and pivot, when you plant your foot in cut, you are putting a lot more pressure on that. So pronation just puts a lot more pressure on the inside edge of that heel growth plate. Casey Bass: So a part of prevention would be as far as preventing this to be to realize your kid has got flat feet, and there is something about that. David Marshall: Yeah, that's a very important part. In fact, I think the best way to treat an overused injury is to prevent it if we can. So, identifying predisposing factors such as flatfeet or pronation, something that's easily correctable with a simple foot orthotic or some arch support that can be purchased at a local drug store, sporting good store, or podiatry office, or a custom Orthotic can be made. Casey Bass: Do you suggest that if my kid has got flatfeet and he plays a lot of sports, that I just go and start trying out orthotic implant? David Marshall: I do. I think if you are going to go, if you are going to drive to Florida on Spring break and you realize you have a flat tire, you are not going to go to put air in that tire. I think we need to treat our feet the same way. Have kids look at their feet, have their doctor look at their feet during their physical and if they pronate, if they have flatfeet, clearly address that, because not only will that help prevent injuries to the heel, also shin splints, knee pain, low back pain, and hip pain have all been linked to not enough air pressure in their tires. Casey Bass: So as a parent if you are just going to go to a drug store and buy an orthopedic, what did you call it? David Marshall: Orthotic. Casey Bass: Orthotic for your kid, are you just looking for the one that's going to square them all the way up. Is that what you are looking for? David Marshall: Yeah, that's basically what you look for. And I think it's okay to have your child take their shoes and socks off in the store and try different types of Orthotics. What you want to see is when they stand in front of you, their Achilles tendon should be perfectly vertical. If they still kind of roll inward or they collapse, then the orthotic isn't nearly high enough or it might not be supportive enough. And there is many different types of orthotics, there is the off the shelf orthotic which is like the Dr. Scholl's Gellin. This is more designed for padding and cushioning and shock absorption rather than rigid support. You can go to a good running shoe company. There is a lot of them in Atlanta that have a semi-custom orthotic. They are going to be a little more rigid, little more padded. Price goes up a little bit anywhere from $60-$90 a pair you might pay, and then the Mercedes-Benz of orthotics who is the full-custom orthotic, where they can actually take a mold of your child's feet, send it to a lab, and build one from scratch and you can pay anywhere from $300-$600 a pair for those. I don't recommend that for young kids that still have the potential to grow, because if you spend that kind of money, and get this beautiful orthotic, 6 months later they grow out of it, then you're left with the pretty expensive dog toy. Casey Bass: So you say the kids walking on his toes because it hurts so much. I ask you this question every time we get together for every condition we talk about, if they are on their toes, maybe I know the answers already. But, can he play or not. David Marshall: With some of these growth plates -- that's a tough question because the growth plates such as little league elbow in young pitchers or little league shoulder, those the answer to that question would be absolutely not, those are the injuries that we really try to encourage kids not to throw, because the continued injury to that growth plate can have much long-term effects, such as needing surgery, or the heel growth plate the ones we talked about on the knee, I think it's okay to let these kids play with little bit of discomfort. Now, you've got to use common sense. I tell the kids it's okay to be tough but it's not okay to be stupid about it. If they are clearly lain, they are limping, they are getting teary-eyed and they are having swelling, then I think common sense is those kids needs to rest. Now, if they can make it through a workout, look okay, not limp considerably, it's not terribly swollen, and they just say yeah, my heel hurts, and my knee hurts a little bit, I don't think the parents should worry about being labeled bad parents by letting their kids play with some minor pain. Casey Bass: Alright. Well doc, thank you so much. We really appreciate it. I hope you'll come back and join us. I am just going to wrap it up for us today. We are going to see you right back here next time for anther great edition of ClubHouseGas.