What is the appropriate evaluation and treatment for a 4-year-old child presenting with heel pain?

Heel Pain in a 4-Year-Old Child

Initial Evaluation

Begin with a focused history and physical examination to determine if the pain can be localized and whether signs of infection are present, as this will guide your imaging strategy. 1

Key History Elements to Obtain

• Trauma history: Determine if there was a fall, inversion injury, or increased walking/running activity 1, 2
• Fever or systemic symptoms: Presence suggests infection (septic arthritis, osteomyelitis, or discitis) 1
• Activity-related pain: Progressive worsening with activity suggests stress fracture or apophysitis 2, 3
• Ability to bear weight: Refusal to walk or limp is common in children under 5 years 1

Critical Physical Examination Findings

• Point tenderness localization: Palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and calcaneofibular ligament 2
• Calcaneal squeeze test: Compress the calcaneus from medial to lateral—pain suggests stress fracture 2, 3
• Signs of infection: Check for fever, erythema, swelling, elevated inflammatory markers (WBC, ESR, CRP) 1
• Gait analysis: Observe for antalgic gait patterns 1

Most Common Diagnoses in This Age Group

Sever's disease (calcaneal apophysitis) is the most common cause of heel pain in children and adolescents 2, 4, though it typically presents in older children (ages 8-14) rather than age 4.

In a 4-year-old specifically, the most likely diagnoses are:

• Occult fracture (particularly spiral tibial "toddler's fracture"): Most common fracture in children <4 years presenting with limp or refusal to bear weight 1
• Calcaneal stress fracture: Presents with progressive pain after increased activity, positive squeeze test 2, 3
• Trauma-related injuries: Ankle/foot fractures, soft tissue injuries 1
• Infection: Must be excluded if fever or systemic signs present 1

Imaging Strategy

If Pain Cannot Be Localized (Common in 4-Year-Olds)

Order limited tibial/fibula radiographs as the initial study rather than full lower extremity radiographs 1, as spiral tibial fractures are by far the most common fractures in this age group presenting with nonlocalized symptoms.

• Initial radiographs are often normal (fracture incidence 4-20%) 1
• Approximately 10% of tibial fractures are only visible on follow-up radiographs 1

If Pain Is Localized to the Heel

Obtain weight-bearing radiographs of the foot as the initial imaging modality 2 to exclude:

• Calcaneal fracture
• Bone lesions
• Other osseous pathology

If Initial Radiographs Are Negative But Symptoms Persist

Perform clinical reassessment and consider:

• Follow-up radiographs in 7-10 days: May reveal fractures not visible initially 1
• Technetium bone scan: Sensitive for stress fractures before radiographic changes appear 2, 3
• MRI without contrast: Equivalent to CT for detecting occult fractures, stress reactions, soft tissue pathology, and infection 1, 2

Treatment Approach

For Sever's Disease/Calcaneal Apophysitis (If Diagnosed)

• Physical therapy program: Lower extremity stretching, especially heel cords and ankle dorsiflexion strengthening 5
• Orthotics: Soft heel cups or Plastizote orthotics in 98% of cases 5
• Activity modification: Reduce high-impact activities temporarily 5
• NSAIDs: For pain and inflammation 5
• Proper athletic footwear 5
• Expected improvement and return to activity within 2 months 5

For Suspected Fracture

• Immobilization and protected weight-bearing 2
• Follow-up imaging if initial radiographs negative 1
• Children are less likely than adults to require surgical treatment 6

For Nonspecific Heel Pain Without Clear Diagnosis

• Conservative management: Rest, activity modification, NSAIDs 7
• Heel cushions or arch supports 7
• Ice massage and stretching 7

Critical Pitfalls to Avoid

Do not discharge a child with persistent symptoms after negative initial imaging without arranging close follow-up 1—one case report describes a child initially discharged who returned with spinal discitis and epidural abscess.

Reexamine 3-5 days post-injury if initial examination was limited by swelling and pain 2, as excessive swelling within 48 hours can obscure findings.

Maintain high suspicion for infection if fever, elevated inflammatory markers, or systemic symptoms are present 1—these children require urgent evaluation and may need joint aspiration or advanced imaging.

Consider rare but serious causes (tumors, infections, vascular compromise) 2, 3 if:

• Pain is constant at rest
• Pain is unrelated to activity
• Symptoms are bilateral or involve other joints
• No improvement with conservative measures

When to Refer

• Immediate subspecialist referral: Suspected infection, neurologic symptoms, or need for advanced diagnostic testing 2, 8
• Orthopedic referral: No improvement after 6-8 weeks of appropriate conservative treatment 2
• Consider referral: Suspected tumor, complex fracture, or need for surgical intervention 2, 6