Clinical Features
- Ask about trauma, onset, activity, night pain and systemic symptoms
- Age and skeletal maturity narrow the diagnosis
- Check for limp, swelling, warmth, focal tenderness and hindfoot motion
- Examine foot posture, spine and neurological status
Differential Diagnosis
Trauma
- Physeal fractures of distal tibia and fibula
- Tillaux and triplane fractures during physeal closure
- Avulsion of the lateral malleolus tip
- Ankle sprain, less frequent before physeal closure
Overuse
- Sever disease, calcaneal apophysitis in active children aged 8 to 12
- Accessory navicular with medial midfoot pain
- Posterior impingement from os trigonum
- Stress fracture
Osteochondral
- Talar osteochondral lesion
- Köhler disease of the navicular in young children
Structural
- Tarsal coalition with rigid flatfoot and recurrent sprains
- Cavovarus foot with lateral instability
Infection and inflammation
- Septic arthritis and osteomyelitis
- JIA, reactive arthritis and enthesitis related arthritis
Neoplastic
- Osteoid osteoma with night pain relieved by NSAIDs
- Calcaneal bone cyst, leukaemia and Ewing sarcoma
Other
- CRPS, more common in adolescent girls
Investigations
- Ottawa ankle rules reduce radiograph use in children
- AP, mortise and lateral ankle radiographs
- CT for Tillaux and triplane fracture displacement
- FBC, ESR, CRP, ultrasound and aspiration for suspected infection
- MRI for osteochondral lesion, stress fracture, occult infection or tumour
- CT for tarsal coalition
Management
- Treat the underlying cause
- Tillaux and triplane fractures displaced over 2 mm need reduction and fixation
- Sever disease settles with activity modification, heel raise and stretching
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.