10 year old kid presents to the office complaining of pain to the posterior achilles insertion left foot.  Walks like an "old man".  Normal development history.  No family history. No trauma. Completely normal medical history.  No other incitin events.  Plays baseball, basketball, football, runs track, NEVER rest!

Exam:  Marked palpation tenderness to the posterior achilles inserion.  5/5 muscle strength.  NO warmth, no evident skin pathology or foreign body. Pain with dorsiflexion of  the foot.  X-Rays reveal:  sawtooth appearance to calcaneal apophysis and slightly sclerotic appearing. No fractures.

Diagnosis:  Severe's disease right????  Not so fast......

Rest, off sports, NSAIDS, casting, gentle streching, heel lifts, massage, etc.....NO better, WORSE!  Steroid pak, WORSE!

MRI.........."Foreign body, not visualized on clinic x-rays, directly under area of pain.

Hmmmm.......foreign body.....are you kidding me????  Bring that kid back in, he did'nt mention stepping on anything.

Inspection:  NO visible foreign body or entry wound.  Transluminate heel side to side with 2 million candlepower lights, NOTHING under skin.   MRI reveals thorn shaped foreign body possibly glass or wood in the dermal layer.

Still shocked.  Can't find anything.  Pain worse.  Let's go hunting.........

Consent for exploration/removal of foerign body in the OR.  Kid and surgeon each draw a dot on the skin where the worse pain is located.  A curvalinear incision used to maximize exposure.  At first glance, fat looks dark and very infitrated/hyupertrophic.  NO foreign body located!  SUDDENLY, in the wall of the dermis, there looks to be a gray discolores mass.  Try to cut it out but you are button holing your medial incision wall. I know, lets cut a wedge of skin out and include the "foreign body" in the wegde of skin.

Three days later, Pathologist call to tell you that the object which you thought  foreign body turns out to be an angiolipoma.  It appears by cutting out the wedge of skin that I got lucky and excised the whole thing.

Lesson learned:  Things are NOT always what they seem.  Angiolipoma of the heel is a painful nodule that is usually benign. This is a not so common cause of heel pain.