The Calcaneal Squeeze Test is a simple yet highly valuable physical examination maneuver in diagnosing heel pain, especially among children and adolescents. It plays a pivotal role in identifying specific pathologies such as Sever’s disease (calcaneal apophysitis) and calcaneal stress fractures. This essay explores the history, anatomy, procedure, clinical relevance, interpretation, differential diagnosis, limitations, and recent perspectives of the Calcaneal Squeeze Test in clinical practice.
Historical Context and Introduction
Heel pain in pediatric and adolescent populations can result from various causes; however, Sever’s disease and calcaneal stress fractures are among the most common. The Calcaneal Squeeze Test was designed as a quick, noninvasive clinical tool to help distinguish these entitities from other etiologies of heel pain. Although initially described for use in pediatrics, the test is also relevant for adults with suspected calcaneal injuries.
Anatomy and Pathophysiology
The calcaneus, or heel bone, is the largest tarsal bone, forming the foundation of the rear part of the foot. The posterior aspect contains the calcaneal apophysis—where the Achilles tendon inserts, and growth commonly occurs in children. In calcaneal apophysitis (Sever’s disease), inflammation and microtrauma at this growth plate lead to pain, especially in physically active children. Meanwhile, a calcaneal stress fracture arises from repeated overuse, often seen in runners and athletes.
Purpose and Indications
The primary clinical indication for the Calcaneal Squeeze Test is to assess the presence of pain or pathology within the calcaneus. It helps diagnose:
- Sever’s disease (children/adolescents)
- Calcaneal stress fractures (especially in athletes)
- Less commonly, other pathologies (infection, tumor, bursitis, plantar fasciitis).
Test Procedure
The test is performed with the patient in a seated or supine position, foot relaxed. The examiner cups the posterior aspect of the patient’s heel using both hands—placing the thumb and fingers on the medial and lateral sides of the calcaneus. Gentle yet firm compression is applied medially and laterally:
- Patient sits or lies down, foot relaxed.
- Examiner uses thumb and fingers to grasp either side of the heel.
- Compression is applied to both sides simultaneously, focusing pressure directly over the growth plate or midbody of the calcaneus.
- The examiner observes and inquires about any pain responses during compression.
Positive vs. Negative Test
- Positive Test: A positive result is indicated by pain that is localized to the compressed area. This suggests possible Sever’s disease in children or a calcaneal stress fracture in adults.
- Negative Test: Absence of pain or discomfort points to a lower likelihood of these pathologies and prompts consideration of alternative diagnoses.
Differential Diagnosis
As heel pain can result from multiple causes, the Calcaneal Squeeze Test helps narrow the differential diagnosis:
- Sever’s Disease: Pain specifically elicited during the squeeze, especially in physically active children.
- Calcaneal Stress Fracture: Pain in adults/athletes, often associated with a history of overuse or trauma.
- Plantar Fasciitis: Typically produces pain upon palpation of the plantar heel (not medial/lateral compression).
- Heel Pad Atrophy/Bursitis: Pain localized to the fat pad or insertion, often discerned using a variation called the fat pad squeeze test.
Clinical Value and Interpretation
The test is valued for its simplicity and utility. In children with a positive squeeze test, Sever’s disease becomes strongly suspected, especially with corroborating clinical history (activity-related pain, recent growth spurt). In adults or adolescents, a positive result with a relevant history suggests a possible stress fracture.
The result must always be interpreted in the context of the full clinical picture. If pain is elicited elsewhere (plantar surface, achilles insertion), other diagnoses should be considered and further imaging (like X-rays or MRI) may be necessary to rule out complex or multilayered injuries.
Limitations
Despite its utility, the Calcaneal Squeeze Test has limitations:
- It is not specific for one pathology alone; both Sever’s disease and stress fractures can yield similar positive findings.
- It may not reliably distinguish between inflammatory, infectious, or neoplastic causes.
- In early-stage disease, sensitivity may be reduced—patients may not always reproduce pain on examination.
- Imaging may still be required for definitive diagnosis when clinical suspicion remains high despite a negative or equivocal test.
Advances and Recent Perspectives
Recent practice embraces the Calcaneal Squeeze Test as an initial assessment, supplemented by imaging where history and exam are inconsistent. The test’s gentle nature ensures safety, especially among children, and allows for repeated evaluation to track response to treatment. Newer research suggests pairing the squeeze test with other maneuvers (e.g., the fat pad squeeze test) for a more comprehensive evaluation of heel pain.
Clinical Example
Consider a 10-year-old soccer player presenting with bilateral heel pain, worsened after running and improved with rest. A positive result on the calcaneal squeeze test strongly supports a diagnosis of Sever’s disease, particularly when matched with age and activity history. Early identification allows for rest and load management, reducing recovery times and preventing chronic pain syndromes.
The Calcaneal Squeeze Test is an invaluable in-office examination technique that can streamline the diagnosis of heel pain—especially Sever’s disease in children and calcaneal stress fractures in active individuals. Its straightforward methodology, non-invasiveness, and diagnostic utility make it a staple in orthopedic, pediatric, and sports medicine settings. Proper application, combined with clinical judgment and selective imaging, optimizes patient outcomes in the evaluation of heel pain.