The overlooked role of Achilles tendon injury in pediatric heel pain: a retrospective comparative study with implications for diagnosis

Abstract

Background No clear clinical diagnostic delineation exists between calcaneal apophysitis and Achilles tendinopathy for patients under 18 years old with posterior heel pain. As misdiagnosis and misaligned treatment of Achilles tendon injury in children may lead to long-term health detriments, it is necessary to compare aspects of Achilles tendon health between individuals diagnosed on either side of the adult age threshold. The study purpose was to compare Achilles tendon symptoms, structure (morphology and mechanical properties), and lower limb impairments between children (aged 7–17) with heel pain and young adults (aged 18–25) with Achilles tendinopathy.

Methods This retrospective cross-sectional analysis included 21 children diagnosed with heel pain (i.e., Sever’s disease; 9 F, 11±2 [range: 8–15] years) and 24 young adults diagnosed with Achilles tendinopathy (14 F, 21±2 years) in cohort studies performed between 2018 and 2024. Pain and symptoms were evaluated via Achillestendon pain on palpation (0–10 scale) and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire .Achilles tendon morphology (free tendon length, cross-sectional area, thickness) was measured using B-mode ultrasound and tendon mechanical properties of shear modulus and viscosity were measured using continuous shear wave elastography. A test battery assessed lower limb function during single-leg counter-movement jump (CMJ), drop CMJ, hopping, and heel-rise endurance tests. Achilles tendon symptoms in the most symptomatic limb and limb symmetry index structural and functional measures were compared between groups using multivariate analyses of covariance.

Results There were no differences in symptoms, Achilles tendon structure, or lower limb function between children with heel pain and young adults with Achilles tendinopathy. Pooled group means revealed that both diagnoses demonstrated mild Achilles tendon pain (insertion: 1/10, midportion: 3/10) and moderate symptoms (VISAA: 64/100pt). Though, children reported pain on palpation at both the Achilles tendon insertion and midportion more frequently (62%) than adults (0%).

Conclusions The lack of difference in clinical presentation observed between children and young adults suggests calcaneal apophysitis and Achilles tendinopathy may not be mutually-exclusive diagnoses in children; supporting the consideration of Achilles tendon overuse symptoms in pediatric patients.