Heel pain is pesky, so let's get rid of this once and for all!
Heel pain in gymnasts (and other young athletes) is a real, sometimes mysterious (for parents and providers), and serious problem. Because of heel pain, I’ve seen young gymnasts sit-out more than a year in order to reduce the pain in their heels. Their parents and medical providers felt there was no other choice but to quit gymnastics to reduce the pain and allow their heels to heal.
To understand heel pain in gymnasts, you first have to understand gymnastics and its interaction with the leg and foot. Heel pain is a direct result of participation in athletics, particularly landings and take-offs. Young athletes have growth plates that are very active and when combined with intense work, they are usually the weak areas taking the brunt of their long hours during practice.
Heel pain in the child and adolescent gymnast is a condition referred to as Sever’s Disease. The gymnast’s skeleton is made of bones and long bones. Bone growth occurs at the ends of bones, or in regions that are well defined, called “growth plates.”
Growth plates, because they are active areas of change, are weaker than surrounding mature bone that has completed growth. Sever’s Disease is an irritation and an inflammation of the growth plate in the heel.
In gymnastics, we produce the “perfect storm” for Sever’s.
Over-pronation of The Arch and Foot
There are multiple reasons why the growth plate in the back of the heel becomes irritated. In athletes of soccer, lacrosse, and football, it usually stems from running on a foot that overpronates. Over-pronation refers to a natural foot position where the foot tilts toward the big-toe side. Over-pronation also puts pressure on the growth plate in the heel by a gait that is altered. Overpronation of the foot can put undue pressure on the heel and achilles tendon.
Many gymnasts that experience heel pain are overpronated in the feet or have flat feet, and sometimes it is made worse because they are running around barefoot with absolutely no support of their arches.
Interaction of The Foot/Heel with The Springs in The Floor and Vault
The Achilles tendon attaches just above the growth plate in the heel. This growth plate can be aggravated by the constant and rapid contraction of the muscles of the calf. The tensile forces applied by the calf muscles through the Achilles tendon to the calcaneus (heel bone) can be so large that the weaker growth plate is irritated.
Bone is a strong material, but bone is strongest when the forces are applied via compression. Bone is considerably weaker when the applied forces come from tension, bending, or shear. From below, the growth plate can be irritated by running around the gym in bare feet, and from above, the force that occurs during a “punch” on floor can create incredible amounts of tension and shear to the growth plate.
There is so much force created for our gymnast’s achilles tendons and growth plates, that one of the major injuries occurring in college gymnasts is achilles tendon ruptures. It’s the same mechanism occurring in both the Sever’s inflicted gymnast and the ruptured achilles gymnast. The difference is that the weak point for the younger gymnast is the growth plate. The older, mature gymnast has no other outlet for the stress occurring during the “punch”. The achilles tendon takes the brunt of the stress.
We’ve found that long term rest does not affect heel pain at all. As soon as the athlete returns to the gym after rest, the symptoms return. Of course, it’s very important that you listen to your medical providers recommendation, but most of your providers have never seen a gymnast with Sever’s disease. Rest is their default recommendation for any musculoskeletal injury. Sometimes rest is the best advice, but with Sever’s, it doesn’t work.
What does work is getting at the root of the issue when it comes to Sever’s disease. What are the root issues that we have to address? Here they are:
Now let’s get into the nuts and bolts of the Gymnast Care Sever’s Disease Protocol, designed and tested with thousands of gymnasts and other athletes.
The following is the Sever’s Disease protocol used with thousands of young gymnasts. If you don’t think you can follow through with the following protocol, give this protocol to your physical therapist, athletic trainer, massage therapist or chiropractor to allow your gymnast to get maximum benefits from the protocol.
The stretching and icing should be done every hour on the hour the gymnast is at home or inactive at the gym. Stretching and icing hourly is a critical step to reducing inflammation.
The massage should be done every other day by the parents or a professional and compression as much as possible, and definitely overnight.
When doing the full protocol on the same day, massage, stretch, and ice in that order, then repeat the stretch and cold water soak every hour on the hour.
Massage the calves from the knees to the heel, concentrating on the achilles tendon and where the muscles meet the tendon. Utilizing instrument assisted soft tissue therapy works amazingly well, even though it is a bit intense for the athlete.
At home, you can use your hands, and knuckles work great to work the Achilles tendon as long as you’re not too rough. We recommend every other day with massage, making sure to give 72 hours rest before competition.
Massage should be firm, but not so firm as to cause injury.
Remember, the calves, and especially the Achilles tendon region will be extremely tender. Your athlete will experience discomfort when doing this.
Use your knuckles when nearing the Achilles tendon. The space between your knuckles is the perfect width to contain the Achilles tendon and this allows for a great massage of this structure.
Make sure to move the foot from flexion into extension (flex and point) during the entire massage. This pumping motion is extremely important and KEY to increasing range of motion and increasing pliability of the achilles tendon.
Stretch both calf muscles in each leg for 30 seconds. Stand with both feet on the stairs, and allow one heel to drop off the stair. Keep the ball of your foot on the edge of the stair. Keeping your knee straight, let gravity gently pull you into a nice stretch for 30 seconds. At the end of 30 seconds, bend your knee and once again letting gravity pull your heel down, stretch for 30 seconds. This stretch will be felt at the bottom of the leg and even around the ankle.
Repeat both stretches on the other leg.
Cold water soak using a cold water bath that covers both the foot and the calf. This will help to decrease the inflammation throughout the leg and foot.
To make a cold water bath, fill bucket or trash can with cold water that is 50-54 degrees F. Add ice if needed to reduce temperature to this range.
An ice bath with temperatures below this is unnecessary and can injure your young athlete!
Keep supporting the arches using The X Brace (click here to find them on Amazon) or the low dye taping technique (click here to watch the video) any time barefoot and when you feel you need the extra support.
Supporting the arches has been shown to instantly reduce pain in young athletes by up to 5 points on a scale of 1-10.
Utilize compression for at least 3 hours after each practice, and if possible, at night when you’re sleeping. You can start with a compression sock or use an ace bandage as pictured.
Compression has been shown to increase oxygen supply to damaged tissue and decrease inflammation by supporting athletes lymph systems. You want to use compression with most injured areas of your athletes body.
If you’re reading this but your gymnast does not have Sever’s or you’ve completed the initial protocol and you want to prevent Sever’s from returning, this is my recommendation for this. It’s also a great way to prevent achilles tendon stress.
After your gymnast’s initial pain is gone, it is important to maintain the flexibility and increased pliability you’ve created in their calves. Here is an example plan for your gymnast and you to stick with:
Sever’s disease does not have to cause your gymnast immense amounts of pain and it definitely doesn’t need to end your gymnast’s career.
Stick with the protocol and you'll see amazing results!
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