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The Pediatric
Patient Presenting
with Bilateral, Non-
Traumatic, Heel
Pain
B y : M o r g a n M a r i e L o n g t i n
N 5 8 9 - M a t e r n a l & P e d i a t r i c C a r e
P r a c t i c u m
F o r t h e A m e r i c a n S e n t i n e l C o l l e g e o f
N u r s i n g a n d H e a l t h S c i e n c e s F N P
M o r g a n M. L o n g t i n - S t u d e n t F N P, B S N
Subjective: History & ROS
- (^) No pertinent PMH, active problems, and surgical hx
- (^) Family history + for HTN, HD, and Diabetes-Type 1- not likely pertinent
- (^) Medications: multivitamin, daily daily Zyrtec, and epi pen for bee stings
- (^) Allergies:
- (^) Bee stings: anaphylaxis
- Mold & smuts- allergic rhinitis/congestion
- (^) ROS
- (^) Constitutional: Negative for any recent injury or triggering event, history of foot/heel problems or injuries, and activity or functioning change.
- (^) Musculoskeletal: Negative for arthralgias, gait problem, joint swelling and myalgias. Positive for bilateral heel pain, right worse than left.
- (^) Skin: Negative for color change, pallor, rash and wound.
- (^) Neurological: Negative for tremors, weakness, sensation changes, and numbness/tingling.
O b j e c t i v e : P h y s i c a l E x a m Vitals: BP 124/60 | HR 71 | Temp 98.3 | RR 20 | SpO 98% Wt 190 lb (86.2 kg) | Height 6’3” | BMI:
Exam:
- Constitutional: WDL
- (^) Musculoskeletal: o (^) R) & L) ankles and Achilles Tendon’s WDL. o (^) R) foot ROM WDL, no swelling, deformity, crepitus, ecchymosis, POSITIVE for tenderness to superior growth plate of right heel. o (^) L) foot ROM WDL, no swelling, deformity, crepitus, ecchymosis, POSITIVE for tenderness to plantar growth plate area of left heel.
- (^) Skin: WDL
- (^) Neurological: WDL in bilateral lower extremities with intact motor function and
T O P D I F F E R E N T I A L S
1. Sever’s Disease/Calcaneal Apophysitis, bilateral
2. Plantar fasciitis, bilateral
3. Calcaneal fracture/stress fracture
4. Heel contusion
5. Achilles tendinitis or tendon injury/tear
6. Posterior ankle impingement
7. Osteomyelitis
(Chorley et al., 2022; Fare et al., 2021; Noffsinger, 2023; Smith & Varacallo, 2022)
A S S E S S M E N T : V I S I T D I A G N O S I S Sever's apophysitis, bilateral M92.
- (^) Disease processes:
- (^) Pain etiology related to fast growth &
repeated micro-trauma
- (^) Self-limiting condition
- (^) Typically resolves w/o complication
- (^) Risk factors:
- (^) Males (2-3X more)
- (^) Pediatrics 8-15 years old
- (^) Improper foot/heal support
- (^) Higher BMI/height
- (^) Sports/activities with excessive
running/jumping
Pes cavus of both feet Q66.
- (^) Also known as having “flat feet”
- (^) Can predispose to-
- (^) Plantar fasciitis
- (^) Sever’s apophysitis
- (^) Foot/ankle injury
- (^) Related knee/back problems (Fare et al., 2021; Noffsinger, 2023; Smith & Varacallo, 2022)
Patient & Family Education
- (^) General information about Sever’s Disease, pathology, prognosis, and
expectations
- (^) Treatment plan:
- (^) Home interventions and care
- (^) Medication education
- (^) Activity recommendations
- (^) Physical therapy expectations
- (^) Red flags warranting medical attention
- (^) Referrals and appointment date
- (^) Follow-up plan of care (Chorley et al., 2022; Fares et al., 2021; Noffsinger, 2023; Smith & Varacallo, 2022; Urelli et al., 2017)
Billing Code Analysis
- (^) Initial Visit: 99213
- (^) Low complexity
- (^) Moderate amount of visit elements
- (^) Low risk
- (^) 3-Month Follow-Up Visit: 99212 or 99213
- (^) Low complexity
- (^) Low-moderate amount of elements
- (^) Low risk (UChicago Medicine, 2022)
R E F E R E N C E S
Alfaro-Santafé, J., Gómez-Bernal, A., Lanuza-Cerzócimo, C., Alfaro-Santafé, J. V., Pérez-Morcillo, A., & Almenar-Arasanz, A. J. (2021) Effectiveness of custom-made foot orthoses vs. heel-lifts in children with calcaneal apophysitis (Sever's Disease): A CONSORT-Compliant Randomized Trial. Children (Basel), 8 (11), 963. https://doi.org/10.3390%2Fchildren Chorley, J., Molina, D., Hergenroeder, A. C., Bachur, R. G., & Grayzel, J. (2022). Heel pain in the active child or skeletally immature adolescents Overview of causes. Up-To-Date. https://www.uptodate.com/contents/heel-pain-in-the-active-child-or-skeletally-immature-adolescent-overview-of-causes Fares, M. Y., Salhab, H. A., Khachfe, H. H., Fares, J., Haidar, R., & Musharrafieh, U. (2021). Sever’s Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clinical Medicine & Research, 19 (3), 132-137. http://www.clinmedres.org/content/19/3/132.full.pdf+html Noffsinger, M. A. (2023). Calcaneal Apophysitis (Sever Disease). Medscape. https://emedicine.medscape.com/article/1237477-overview Smith, J. M. & Varacallo, M. (2022). Sever Disease. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK UChicago Medicine. (2022). Tip sheet: Outpatient evaluation and management services (CPT codes 99202-99215). University of Chicago. https://compliance.bsd.uchicago .edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdf Uvelli, K., Neher, J. O., & Safranek, S. (2017). Treatment for Calcaneal Apophysitis. American family physician , 96 (2), 126–127. https://www.aafp.org/pubs/afp/issues/2017/0715/p126.html
