What is the best course of action for a 9-year-old athletic girl experiencing bilateral foot pain, primarily below the ankles, that interferes with her sleep?

Bilateral Foot Pain in a 9-Year-Old Athletic Girl

This is most likely calcaneal apophysitis (Sever disease), and you should initiate conservative treatment immediately with activity modification, ice therapy, heel cushions, stretching exercises, and NSAIDs for pain relief. 1, 2

Initial Clinical Assessment

Key History and Physical Examination Findings to Obtain

• Pain location specificity: Determine if pain is at the posterior heel (Achilles insertion), lateral heel, or diffuse throughout the heel 1, 2
• Activity correlation: Ask about recent increases in training intensity or changes to harder surfaces, which strongly suggests calcaneal stress fracture or apophysitis 2
• Footwear assessment: Pain relieved when barefoot but worsened by shoes suggests Haglund's deformity or bursitis 1, 2
• Calcaneal squeeze test: Compress the calcaneus from medial to lateral—pain with this maneuver is highly suspicious for stress fracture 2
• Palpation: Tenderness at the Achilles insertion or lateral calcaneal wall helps differentiate diagnoses 2, 3

Most Likely Diagnosis

Calcaneal apophysitis (Sever disease) is the most common cause of heel pain in athletic children and adolescents. 2 Given the bilateral presentation, athletic activity, and age, this is your primary diagnosis until proven otherwise.

Immediate Management Plan

First-Line Conservative Treatment (Implement All Simultaneously)

• Activity modification: Reduce or temporarily stop high-impact activities that worsen pain, but avoid complete rest to prevent muscle weakness 1
• Ice therapy: Apply ice through a wet towel for 10-minute periods to reduce pain and inflammation 1
• Heel cushions or lifts: Use over-the-counter heel cushions and arch supports to redistribute weight and reduce pressure 1
• Stretching exercises: Prescribe calf muscle and plantar fascia stretches 3-5 times daily—this is the most consistently effective intervention 1
• NSAIDs: Ibuprofen for short-term pain relief and inflammation reduction 1
• Proper footwear: Ensure shoes have adequate arch support and cushioning 1
• Weight management: If indicated, address this to reduce pressure on the heel 1

Expected Timeline and Follow-Up

Most patients respond to conservative treatment within 6-8 weeks. 1 Schedule follow-up at 6 weeks to assess response.

When Initial Radiographs Are Indicated

You do NOT need radiographs initially if the clinical presentation is classic for Sever disease. 4 However, obtain plain radiographs of both feet if:

• Pain persists beyond 4 weeks despite conservative treatment 4
• Physical examination reveals concerning findings (point tenderness over specific bones, severe swelling, inability to bear weight) 4
• You suspect stress fracture (positive calcaneal squeeze test, progressively worsening pain) 2
• Night pain or constant pain at rest is present—these are red flags requiring immediate imaging 4

Differential Diagnoses to Consider

If Pain Is Posterior and Lateral

• Haglund's deformity with retrocalcaneal bursitis: Prominent posterior superior calcaneus, pain worse with shoes 2, 3
• Insertional Achilles tendinopathy: Pain at tendon insertion, relieved barefoot 3

If Pain Is Diffuse

• Calcaneal stress fracture: Progressive worsening with activity, positive squeeze test, may require bone scan or MRI as symptoms precede radiographic findings 2

Red Flags Requiring Immediate Specialist Referral

• Neurologic symptoms: Burning, tingling, numbness—requires immediate subspecialist evaluation with EMG, nerve conduction studies, and MRI 2, 3
• Constant pain at rest or night pain: Suggests infection, tumor, or severe pathology 4
• Bilateral symptoms with joint pain elsewhere: Consider inflammatory arthritis 2

Escalation Algorithm

At 6-8 Weeks: If No Improvement

Refer to a pediatric orthopedic surgeon or podiatric foot and ankle surgeon. 4, 1 At this point, consider:

• Advanced imaging: MRI without contrast or technetium bone scan to evaluate for stress fracture or other occult pathology 4, 2
• Immobilization: Cast or fixed-ankle walker-type device 1
• Custom orthotics: If over-the-counter devices have failed 1

Critical Pitfall to Avoid

Never inject corticosteroids near the Achilles tendon—this significantly increases the risk of tendon rupture. 1, 3 If considering corticosteroid injection for bursitis, ensure it is NOT near the tendon insertion.

Sleep Disturbance Management

The sleep disruption is likely secondary to pain. Adequate pain control with NSAIDs at bedtime and ice therapy before sleep should improve sleep quality. 1 If sleep problems persist despite pain control, consider formal sleep evaluation, as sleep disorders are common in pediatric populations and can negatively affect behavior, cognition, and physical health. 4

Key Takeaway for This Patient

Start all conservative measures immediately without waiting for imaging, reassess at 6 weeks, and refer to pediatric orthopedics only if no improvement occurs. 1 The bilateral nature and athletic activity make Sever disease the overwhelming favorite, and this condition responds excellently to conservative management in the vast majority of cases.