What is the appropriate management for a 14-year-old male experiencing pain?

Management of Heel Pain in a 14-Year-Old Male

For a 14-year-old male with heel pain, begin with acetaminophen 650-1000mg every 8 hours (maximum 4000mg/24 hours) as first-line pharmacological treatment, combined with activity modification and physical therapy, while conducting a focused evaluation to rule out serious underlying pathology such as bone tumors, infection, or inflammatory arthritis. 1, 2, 3

Initial Assessment Priorities

The evaluation must systematically exclude serious pathology before attributing pain to common benign causes:

• Red flags requiring urgent evaluation: Night pain, constitutional symptoms (fever, weight loss), progressive pain unrelated to activity, or focal neurological findings suggest malignancy, infection, or inflammatory conditions 4, 5
• Pain characteristics to document: Onset (acute macrotrauma vs. gradual overuse), location (posterior heel suggests Sever's disease/calcaneal apophysitis; plantar suggests plantar fasciitis), aggravating factors (worse with activity suggests mechanical; worse at rest/night suggests inflammatory or neoplastic), and duration 1, 5
• Functional impact assessment: Specific activities the patient cannot perform (sports participation, walking to school, climbing stairs) rather than focusing solely on pain intensity scores 1
• Growth-related factors: Adolescents undergoing rapid growth spurts are at increased risk for apophyseal injuries, particularly in the heel 5

Diagnostic Workup

• Physical examination essentials: Palpate the calcaneal apophysis (tenderness suggests Sever's disease), assess for pes planovalgus (flat feet), examine gait pattern, check for Achilles tendon tightness, and evaluate ankle range of motion 4, 5
• Imaging indications: Plain radiographs are warranted if trauma history exists, pain persists beyond 4-6 weeks despite conservative treatment, or red flags are present 5
• Laboratory testing: Consider complete blood count, inflammatory markers (ESR, CRP), and rheumatologic workup only if inflammatory arthritis is suspected based on morning stiffness, joint swelling, or systemic symptoms 4, 6

Stepped-Care Treatment Algorithm

First-Line Management (Weeks 1-4)

• Pharmacological: Acetaminophen 650-1000mg every 8 hours with meals (maximum 4000mg/24 hours), avoiding combination products that may contain hidden acetaminophen 1, 2, 3
• Activity modification: Reduce high-impact activities (running, jumping) but maintain low-impact exercise (swimming, cycling) to prevent deconditioning 4, 1
• Physical interventions: Ice application 15-20 minutes three times daily, heel cups or cushioned inserts for shock absorption, and gentle Achilles stretching exercises 5
• Patient education: Explain that heel pain in adolescents is typically self-limited, resolving with skeletal maturity, and that complete rest is counterproductive 4, 1

Second-Line Management (If No Improvement After 4 Weeks)

• NSAIDs consideration: Ibuprofen 400mg every 6 hours with food may be used for short courses (7-10 days maximum) in adolescents, though acetaminophen remains safer for longer-term use 4, 2, 7
• Physical therapy referral: Structured program including eccentric strengthening exercises, proprioceptive training, and biomechanical assessment 4, 1
• Orthotic devices: Custom or over-the-counter arch supports if pes planovalgus is contributing, with evidence that orthotics can benefit nonspecific lower leg/foot pain in this population 4

Third-Line Management (Persistent Pain Beyond 8-12 Weeks)

• Multidisciplinary evaluation: Referral to pediatric sports medicine or orthopedics for advanced imaging (MRI if stress fracture or bone pathology suspected) and consideration of alternative diagnoses 4, 1
• Psychological assessment: Screen for pain catastrophizing, anxiety, and depression, which bidirectionally influence pain perception and can perpetuate chronic pain 8, 9
• Cognitive-behavioral therapy: If pain persists and affects function, CBT has high-quality evidence for improving pain-related functioning in adolescents 4, 1

Critical Pitfalls to Avoid

• Never dismiss persistent heel pain in adolescents as "just growing pains" without proper evaluation, as serious pathology including bone tumors, though rare, can present with heel pain 4, 5
• Avoid prolonged NSAID use (beyond 2 weeks) in adolescents due to gastrointestinal and renal risks; acetaminophen is safer for extended use 4, 2
• Do not prescribe opioids for musculoskeletal heel pain in adolescents, as non-opioid alternatives are effective and avoid risks of dependence 4, 2
• Never rely solely on pain intensity scores (0-10 scale) without assessing functional impact, as pain is multidimensional and treatment goals should focus on restoring function 1
• Avoid complete immobilization or prolonged rest, which leads to deconditioning and may paradoxically worsen outcomes; maintain modified activity 4, 1

Monitoring and Follow-Up

• Reassess at 2-4 week intervals to evaluate treatment response using both pain scores and functional measures (return to sports, school attendance, sleep quality) 1
• Red flag monitoring: Any development of night pain, systemic symptoms, or neurological changes warrants immediate re-evaluation with imaging 4, 5
• Expected timeline: Most mechanical heel pain in adolescents improves within 6-12 weeks with conservative management; persistence beyond this timeframe requires specialist referral 5, 9