Sever's Disease: Difference between revisions
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== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
Apophysis have a higher composition of fibrocartilage. The calcaneal apophysis ossifies as an independent ossification center, and usually appears at the of 7-9 years and fuses by the age of 15-17 years. The [[Achilles Tendon]] inserts to the lower, posterior and slightly medial aspect of the calcaneus. The calcaneal growth plate are subjected to high stress from the [[Plantar Aponeurosis|plantar]] and [[Achilles Tendon|Achilles tendon]]<ref name="Scharfbillig">Scharfbillig RW, Jones S, Scutter SD | Apophysis have a higher composition of fibrocartilage. The calcaneal apophysis ossifies as an independent ossification center, and usually appears at the of 7-9 years and fuses by the age of 15-17 years. The [[Achilles Tendon]] inserts to the lower, posterior and slightly medial aspect of the calcaneus. The calcaneal growth plate are subjected to high stress from the [[Plantar Aponeurosis|plantar]] and [[Achilles Tendon|Achilles tendon]]<ref name="Scharfbillig">Scharfbillig RW, Jones S, Scutter SD. Sever’s disease: what does the literature really tell us?. Journal of the American Podiatric Medical Association. 2008 May;98(3):212-23. </ref>. | ||
== Epidemiology /Etiology == | == Epidemiology /Etiology == | ||
Sever’s disease is an osteochondrosis caused by overloading the insertion of the Achilles tendon onto the calcaneus and the apophyseal growth plate in this area. This C-shaped growth zone can become inflamed secondary to repetitive traction stress of the Achilles tendon. It is an overgrowth syndrome and is similar to Osgood-Schlatter disease. Growth is directly proportional to the amount of the stress placed on it. | Sever’s disease is an osteochondrosis caused by overloading the insertion of the Achilles tendon onto the calcaneus and the apophyseal growth plate in this area. This C-shaped growth zone can become inflamed secondary to repetitive traction stress of the Achilles tendon. It is an overgrowth syndrome and is similar to Osgood-Schlatter disease. Growth is directly proportional to the amount of the stress placed on it. | ||
Active children and adolescents (usual age of occurrence: 7 to 15 years), particularly during the pubertal growth spurt or at the beginning of a sport season (e.g. gymnasts, basketball and football players), often suffer from this condition<ref name=":0">Launay F. | Active children and adolescents (usual age of occurrence: 7 to 15 years), particularly during the pubertal growth spurt or at the beginning of a sport season (e.g. gymnasts, basketball and football players), often suffer from this condition<ref name=":0">Launay F. Sports-related overuse injuries in children. Orthopaedics & Traumatology: Surgery & Research. 2015 Feb 1;101(1):S139-47.</ref><ref name=":1">James AM, Williams CM, Haines TP. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review. Journal of Foot and Ankle Research. 2013 Dec 1;6(1):16.</ref>. This disease occurs most commonly during the early part of the growth spurt. A boy-to-girl ratio is 2-3:1.<ref name=":1" /> | ||
It occurs only in the growing children and never occurs after puberty<ref name=":3">Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987 Jan 1;7(1):34-8.</ref> <br> | It occurs only in the growing children and never occurs after puberty<ref name=":3">Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987 Jan 1;7(1):34-8.</ref> <br> | ||
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== Characteristics/Clinical Presentation == | == Characteristics/Clinical Presentation == | ||
This syndrome can occur unilaterally or bilaterally<ref name=":2">Elengard T, Karlsson J, Silbernagel KG. | This syndrome can occur unilaterally or bilaterally<ref name=":2">Elengard T, Karlsson J, Silbernagel KG. Aspects of treatment for posterior heel pain in young athletes. Open access journal of sports medicine. 2010;1:223.</ref>. The incidence of bilaterally is approximately 60%.<br>Common signs and symptoms: | ||
*Pain is usually absent when the child gets up in the morning<ref name=":1" />. | *Pain is usually absent when the child gets up in the morning<ref name=":1" />. | ||
*Increased pain with weight bearing, running or jumping<ref name=":0" /><ref name=":1" /> | *Increased pain with weight bearing, running or jumping<ref name=":0" /><ref name=":1" /> | ||
*Tenderness on medial and lateral heel compression.<ref name=":3" /> | *Tenderness on medial and lateral heel compression.<ref name=":3" /> | ||
*No erythema, swelling or skin changes found. | *No erythema, swelling or skin changes found.<ref name=":3" /> | ||
*Can be associated with foot malalignments. | *Can be associated with other foot malalignments. | ||
*The child may limp at the end of physical activity<ref name="Scharfbillig" /><ref name=":1" />. | *The child may limp at the end of physical activity<ref name="Scharfbillig" /><ref name=":1" />. | ||
*Limited ankle dorsiflexion range secondary to tightness of the Achilles tendon. | *Limited ankle dorsiflexion range secondary to tightness of the Achilles tendon. | ||
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== Differential Diagnosis == | == Differential Diagnosis == | ||
Posterior heel pain can occur due to | |||
* [[Achilles Tendinopathy]] | |||
* [[Haglund's Deformity]] | |||
* [[Retrocalcaneal Bursitis]] | |||
* [[Calcaneal stress Fracture]] | |||
* [[Heel spur]] | |||
* [[Heel pad syndrome]] | |||
== Diagnostic Procedures == | |||
[[File:Calcaneal apohysisitis.jpg|thumb]] | |||
== | === Radiography === | ||
Most of the time radiographs are not helpful because the calcaneal apophysis is frequently fragmented and dense in normal children. But they can be used to exclude other traumas. | |||
=== Ultrasonography === | |||
could show the fragmentation of secondary nucleus of ossification of the calcaneal growth plate. This is a safe diagnostic tool since there is no radiation. This diagnostic tool can also be used to exclude Achilles tendinopathy and/or retrocalcaneal bursitis<ref name="Hosgören">Hosgoren B, Koktener A, Dilmen G. Ultrasonography of the calcaneus in Sever's disease. Indian pediatrics. 2005 Aug 1;42(8):801. </ref>. | |||
<br> | <br> | ||
== Examination == | == Examination == | ||
* Tenderness | * Tenderness on palpation. | ||
*Passive dorsiflexion test of the ankle: shows a decrease in dorsiflexion. This test may also provoke a painful reaction. | *Passive dorsiflexion test of the ankle: shows a decrease in dorsiflexion. This test may also provoke a painful reaction. | ||
*'''Squeeze test''': Mediolateral compression of the calcaneal growth plate to elicit pain in Sever’s disease<ref name="Scharfbillig" />. Performed over the lower one-third of the posterior calcaneus. This test is the most important to diagnose calcaneal | *'''Squeeze test''': Mediolateral compression of the calcaneal growth plate to elicit pain in Sever’s disease<ref name="Scharfbillig" />. Performed over the lower one-third of the posterior calcaneus. This test is the most important to diagnose calcaneal apophysitis. | ||
*Standing tiptoe aggravates the heel pain. | |||
*Standing tiptoe aggravates the heel pain. | |||
*Biomechanical abnormalities: pes valgoplanus, forefoot varus, rear foot varus, pes cavus, pes planus, and hallux valgus. | *Biomechanical abnormalities: pes valgoplanus, forefoot varus, rear foot varus, pes cavus, pes planus, and hallux valgus. | ||
*Swelling and other skin changes are indicators for different pathologic conditions and are uncommon for Sever’s disease. Although there could be mild swelling. | *Swelling and other skin changes are indicators for different pathologic conditions and are uncommon for Sever’s disease. Although there could be mild swelling. | ||
*Gait may be normal; the patient may walk with a limp or exhibit a forceful heel strike. | *Gait may be normal; the patient may walk with a limp or exhibit a forceful heel strike. | ||
*Overweight<br> | *Overweight<br> | ||
== Physical Therapy Management == | == Physical Therapy Management == | ||
As the condition is self-limiting, it resolves as the child matures. Treatment depends on the severity of the child’s symptoms. During the active phase, the patient’s activity level should be limited only by pain. | |||
Treatment: | Treatment: | ||
*Relative Rest/ | *Relative Rest and/or cessation of sports<ref name=":1" />. | ||
*Cryotherapy<ref name=":1" />. | *Cryotherapy<ref name=":1" />. | ||
*Stretching Triceps Surae and | *Tapping | ||
*Silicone heel cup with medial arch support cushions the affected area for shock absorption and helps in reducing pain. | |||
*Orthoses can be prescribed to correct secondary foot malalignments, such as foot in valgus position can disrupt the Windlass mechanism which is important for normal gait.<ref name=":1" /> | |||
*Gentle | *Stretching of Triceps Surae, Plantar fascia to improve dorsiflexion and strengthening of extensors<ref name=":1" /> | ||
*Gentle mobilizations to the subtalar joint and forefoot area<ref name="Leri">Leri JP. Heel pain in a young adolescent baseball player. Journal of Chiropractic Medicine. 2004 Mar 1;3(2):66-8. </ref> | |||
*Electrical stimulation in the form of Russian stimulation sine wave modulated at 2500 Hz with a 12 second on time and an 8 second off time with a 3 second ramp<ref name="Leri" /> | *Electrical stimulation in the form of Russian stimulation sine wave modulated at 2500 Hz with a 12 second on time and an 8 second off time with a 3 second ramp<ref name="Leri" /> | ||
*Ultrasound, nonsteroidal anti-inflammatory drugs. | |||
*Ultrasound, nonsteroidal anti-inflammatory drugs | |||
*Corticosteroid injections are not recommended. | *Corticosteroid injections are not recommended. | ||
*Ketoprofen Gel as an addition to treatment. | *Ketoprofen Gel as an addition to treatment. | ||
Symptoms usually resolve in a few weeks to 2 months after therapy is initiated<ref name=":0" /><ref name=":1" /><ref name=":2" />.<br>In order to prevent calcaneal apophysitis when returning to sports (after successful treatment and full recovery), icing and stretching after activity are most indicated.<br> | |||
== Resources == | == Resources == | ||
Revision as of 16:03, 29 November 2020
Original Editors
Top Contributors - Tassignon Bruno, Wanda van Niekerk, Kim Jackson, Cindy John-Chu, Keta Parikh, Arnold Fredrick D'Souza, Vidya Acharya, Admin, Rachael Lowe, Rucha Gadgil, Pacifique Dusabeyezu, Maarten Cnudde, Naomi O'Reilly, Claire Knott, Meaghan Rieke and Shreya Pavaskar
Definition/Description[edit | edit source]
The term was coined by James Warren Sever in 1912. It is also known as Calcaneal apophysitis. One of the most common cause of heel pain among children, of the age 10-12 years. Calcaneum apophysitis is the painful inflammation of the calcaneal apophysis, which is caused by repetitive microtrauma on the unossified apophysitis due to traction of the Achilles Tendon. Other common traction injuries are Iliac apophysitis, Medial epicondyle apophysitis(Little League elbow), Inferior pole of patella apophysitis(Sinding-Larsen-Johansson), Tibial tubercle apophysitis(Osgood-Schlatter disease), and Fifth Metatarsal bone apophysitis.
Clinically Relevant Anatomy[edit | edit source]
Apophysis have a higher composition of fibrocartilage. The calcaneal apophysis ossifies as an independent ossification center, and usually appears at the of 7-9 years and fuses by the age of 15-17 years. The Achilles Tendon inserts to the lower, posterior and slightly medial aspect of the calcaneus. The calcaneal growth plate are subjected to high stress from the plantar and Achilles tendon[1].
Epidemiology /Etiology[edit | edit source]
Sever’s disease is an osteochondrosis caused by overloading the insertion of the Achilles tendon onto the calcaneus and the apophyseal growth plate in this area. This C-shaped growth zone can become inflamed secondary to repetitive traction stress of the Achilles tendon. It is an overgrowth syndrome and is similar to Osgood-Schlatter disease. Growth is directly proportional to the amount of the stress placed on it.
Active children and adolescents (usual age of occurrence: 7 to 15 years), particularly during the pubertal growth spurt or at the beginning of a sport season (e.g. gymnasts, basketball and football players), often suffer from this condition[2][3]. This disease occurs most commonly during the early part of the growth spurt. A boy-to-girl ratio is 2-3:1.[3]
It occurs only in the growing children and never occurs after puberty[4]
Characteristics/Clinical Presentation[edit | edit source]
This syndrome can occur unilaterally or bilaterally[5]. The incidence of bilaterally is approximately 60%.
Common signs and symptoms:
- Pain is usually absent when the child gets up in the morning[3].
- Increased pain with weight bearing, running or jumping[2][3]
- Tenderness on medial and lateral heel compression.[4]
- No erythema, swelling or skin changes found.[4]
- Can be associated with other foot malalignments.
- The child may limp at the end of physical activity[1][3].
- Limited ankle dorsiflexion range secondary to tightness of the Achilles tendon.
Hard surfaces and poor-quality or worn-out athletic shoes contribute to increased symptoms. The pain gradually resolves with rest. All the sports activity that includes running should be discontinued while the child has heel pain.
Differential Diagnosis[edit | edit source]
Posterior heel pain can occur due to
- Achilles Tendinopathy
- Haglund's Deformity
- Retrocalcaneal Bursitis
- Calcaneal stress Fracture
- Heel spur
- Heel pad syndrome
Diagnostic Procedures[edit | edit source]
Radiography[edit | edit source]
Most of the time radiographs are not helpful because the calcaneal apophysis is frequently fragmented and dense in normal children. But they can be used to exclude other traumas.
Ultrasonography[edit | edit source]
could show the fragmentation of secondary nucleus of ossification of the calcaneal growth plate. This is a safe diagnostic tool since there is no radiation. This diagnostic tool can also be used to exclude Achilles tendinopathy and/or retrocalcaneal bursitis[6].
Examination[edit | edit source]
- Tenderness on palpation.
- Passive dorsiflexion test of the ankle: shows a decrease in dorsiflexion. This test may also provoke a painful reaction.
- Squeeze test: Mediolateral compression of the calcaneal growth plate to elicit pain in Sever’s disease[1]. Performed over the lower one-third of the posterior calcaneus. This test is the most important to diagnose calcaneal apophysitis.
- Standing tiptoe aggravates the heel pain.
- Biomechanical abnormalities: pes valgoplanus, forefoot varus, rear foot varus, pes cavus, pes planus, and hallux valgus.
- Swelling and other skin changes are indicators for different pathologic conditions and are uncommon for Sever’s disease. Although there could be mild swelling.
- Gait may be normal; the patient may walk with a limp or exhibit a forceful heel strike.
- Overweight
Physical Therapy Management[edit | edit source]
As the condition is self-limiting, it resolves as the child matures. Treatment depends on the severity of the child’s symptoms. During the active phase, the patient’s activity level should be limited only by pain.
Treatment:
- Relative Rest and/or cessation of sports[3].
- Cryotherapy[3].
- Tapping
- Silicone heel cup with medial arch support cushions the affected area for shock absorption and helps in reducing pain.
- Orthoses can be prescribed to correct secondary foot malalignments, such as foot in valgus position can disrupt the Windlass mechanism which is important for normal gait.[3]
- Stretching of Triceps Surae, Plantar fascia to improve dorsiflexion and strengthening of extensors[3]
- Gentle mobilizations to the subtalar joint and forefoot area[7]
- Electrical stimulation in the form of Russian stimulation sine wave modulated at 2500 Hz with a 12 second on time and an 8 second off time with a 3 second ramp[7]
- Ultrasound, nonsteroidal anti-inflammatory drugs.
- Corticosteroid injections are not recommended.
- Ketoprofen Gel as an addition to treatment.
Symptoms usually resolve in a few weeks to 2 months after therapy is initiated[2][3][5].
In order to prevent calcaneal apophysitis when returning to sports (after successful treatment and full recovery), icing and stretching after activity are most indicated.
Resources[edit | edit source]
References[edit | edit source]
- ↑ 1.0 1.1 1.2 Scharfbillig RW, Jones S, Scutter SD. Sever’s disease: what does the literature really tell us?. Journal of the American Podiatric Medical Association. 2008 May;98(3):212-23.
- ↑ 2.0 2.1 2.2 Launay F. Sports-related overuse injuries in children. Orthopaedics & Traumatology: Surgery & Research. 2015 Feb 1;101(1):S139-47.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 James AM, Williams CM, Haines TP. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review. Journal of Foot and Ankle Research. 2013 Dec 1;6(1):16.
- ↑ 4.0 4.1 4.2 Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987 Jan 1;7(1):34-8.
- ↑ 5.0 5.1 Elengard T, Karlsson J, Silbernagel KG. Aspects of treatment for posterior heel pain in young athletes. Open access journal of sports medicine. 2010;1:223.
- ↑ Hosgoren B, Koktener A, Dilmen G. Ultrasonography of the calcaneus in Sever's disease. Indian pediatrics. 2005 Aug 1;42(8):801.
- ↑ 7.0 7.1 Leri JP. Heel pain in a young adolescent baseball player. Journal of Chiropractic Medicine. 2004 Mar 1;3(2):66-8.
- ↑ David Piskulic. Case Study Sever's disease. Medbridge. Available from https://www.youtube.com/watch?v=A6Ffiotje2w
