Sever's Disease: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==
[[File:Heel pain.png|thumb]]


Sever’s disease is an overuse syndrome commonly seen in immature athletes competing in running and jumping sports<ref>Ceylan HH, Caypinar B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6064045/ Incidence of calcaneal apophysitis in Northwest Istanbul]. BMC Musculoskelet Disord. 2018; 19: 267.</ref><ref name=":0">Launay F. [https://www.sciencedirect.com/science/article/pii/S1877056814003284?via%3Dihub Sports-related overuse injuries in children]. Orthop Traumatol Surg Res. 2015 Feb;101(1 Suppl):S139-47</ref>. It is also referred to as calcaneal apophysitis or Osgood-Schlatter syndrome of the foot.It was initially described by James Warren Sever in 1912<ref>Sever J. Apophysis of os calcis. NY State J Med. 1912;95:1025</ref>. The basic pathology is repetitive microtrauma from traction of the Achilles tendon at the secondary ossification centre of the calcaneus that causes calcaneal apophysis damage<ref name=":0" />. This traction apophysitis is secondary to repetitive microtrauma or overuse of the heel in young athletes<ref name="Cassas">Cassas KJ, Cassettari-Wayhs A: [http://www.aafp.org/afp/2006/0315/p1014.html Childhood and Adolescent Sports-Related Overuse Injuries]. Dallas, Texas, American Family Physician 73: 1014-1022, 2006. </ref>.<br>  
The term was coined by James Warren Sever in 1912. One of the most common causes of heel pain among children between the ages of 10 to 12 years. Also known as calcaneal apophysitis or calcaneoapophysitis, this condition is the painful inflammation of the calcaneal apophysis caused by repetitive microtrauma on the unossified apophysis due to traction of the [[Achilles Tendon|achilles tendon]]. Other common traction injuries are Iliac apophysitis, medial epicondyle apophysitis or [[Little League Elbow|Little League elbow]], inferior pole of [[patella]] apophysitis or [[Sinding Larsen Johansson Syndrome|Sinding-Larsen-Johansson]] syndrome, tibial tubercle apophysitis or [[Osgood-Schlatter Disease|Osgood-Schlatter disease]], and fifth metatarsal apophysitis.<br>  


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


The calcaneus is situated at the most plantar posterior aspect of the foot. The [[Achilles tendon]] inserts to the lower, posterior and slightly medial aspect of the calcaneus. The plantar fascia originates from the medial tubercle on the plantar aspect of the calcaneus. Proximal to the epiphysis is the apophysis, where the Achilles tendon actually inserts. The calcaneal growth plate and apophysis are situated in an area subject to high stress from the plantar and Achilles tendon<ref name="Scharfbillig">Scharfbillig RW, Jones S, Scutter SD: [http://www.podologiaalicante.com/articulos/sever.pdf Sever’s Disease: What Does the Literature Really Tell Us?] Journal of the American Podiatric Medical Association 98: 212-223, 2008. </ref>. A shortened [[Gastrocnemius|triceps surae]] might also be present as a result of the difference in growth rate between bone and muscle<ref name=":0" />. This occurrence may reduce the cushioning between the foot and the ground<ref name=":0" />. Furthermore, the Achilles tendon has a wide insertion area that is anatomically linked to the plantar aponeurosis<ref name=":0" />. This actually helps to prevent traumatic tears of the ossification centre<ref name=":0" />.
The calcaneal apophysis refers to the back part of the posterior aspect of the calcaneus , where the [[Achilles Tendon|Achilles tendon]] inserts. This area contains the open growth plate called physis. The closure of the [[calcaneus]] growth plate typically occurs around the age of 14.<ref name=":5">Ramponi DR, Baker C. Sever’s Disease (Calcaneal Apophysitis). Adv Emerg Nurs J. 2019;41(1):10–4. </ref> Until that time, new bone is forming at the calcaneal physis. When this growth plate is irritated, it undergoes stress that leads to inflammation. The primary explanation for Sever's injury involves excessive mechanical strain caused by repeated impact pressure and shear forces on the still-developing growth plate of the [[calcaneus]].<ref name=":5" />
 
Apophysis have a higher composition of fibrocartilage. The calcaneal apophysis usually appears in children around 7-9 years old and fuses between the ages 15–17 years of age. The [[Achilles Tendon]] inserts to the lower, posterior and slightly medial aspect of the [[calcaneus]]. The calcaneal growth plates are subjected to high stress from the [[Plantar Aponeurosis|plantar aponeurosis]] and the Achilles tendon.<ref name="Scharfbillig">Scharfbillig RW, Jones S, Scutter SD. [https://doi.org/10.7547/0980212 Sever’s disease: what does the literature really tell us]? Journal of the American Podiatric Medical Association. 2008 May;98(3):212-23. </ref>
 
== Etiology/Risk Factors ==
Sever’s disease is an osteochondrosis caused by overload. This C-shaped growth zone becomes inflamed secondary to repetitive traction stress of the Achilles tendon.


[[Image:Voet apophyse.png|center]]
Risk factors may include:


== Epidemiology /Etiology  ==
* High physical and sporting activities especially those involving repetitive running and jumping
* Heel cord tightness
* Weak ankle dorsiflexion
* Poorly cushioned or worn out athletic shoes
* Running on hard surfaces
* Biomechanical factors such as genu varum, forefront pes cavovarus or pes planus<ref name=":4">Smith JM, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK441928/#_article-28936_s15_ Sever Disease]. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021</ref><ref>McSweeney SC, Reed L, Wearing S. [https://doi.org/10.1177%2F1071100717750889 Foot Mobility Magnitude and Stiffness in Children With and Without Calcaneal Apophysitis]. Foot Ankle Int. 2018 May;39(5):585-590.</ref>
* Obesity<ref name=":6">James AM, Williams CM, Luscombe M, Hunter R, Haines TP. Factors Associated with Pain Severity in Children with Calcaneal Apophysitis (Sever Disease). J Pediatr [Internet]. 2015;167(2):455–9.</ref>
* Greater waist circumference and increased height<ref name=":6" />


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. Calcaneal apophysitis is a common injury in young athletes and is believed to be caused by running and jumping<ref name=":0" /><ref name=":1">James AM, Williams CM, Haines TP. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663667/ Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review.] J Foot Ankle Res. 2013; 6: 16.</ref>.
== Epidemiology ==


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" /><ref name=":1" />. 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" />
Sever's disease is an overgrowth syndrome similar to [[Osgood-Schlatter Disease|Osgood-Schlatter disease]]. Growth is directly proportional to the amount of stress placed on the calcaneal growth plates.


None of these causative factors has been tested prospectively and, where tested, none of the measurements has been carried out systematically, and reliability or validity of the measurements has not been considered<ref name="Scharfbillig" /><ref name=":1" />.<br>  
Active children and adolescents, 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. [https://doi.org/10.1016/j.otsr.2014.06.030 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. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663667/ 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. [https://journals.lww.com/pedorthopaedics/Abstract/1987/01000/Prevention_and_Management_of_Calcaneal_Apophysitis.7.aspx Prevention and management of calcaneal apophysitis in children: an overuse syndrome.] J Pediatr Orthop. 1987 Jan 1;7(1):34-8.</ref>.


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
[[File:Anklesqueezetest.jpg|thumb]]
This syndrome can occur unilaterally or bilaterally<ref name=":2">Elengard T, Karlsson J, Silbernagel KG. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781873/ 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%<ref name=":4" />.<br>Common signs and symptoms:


This syndrome can occur unilaterally or bilaterally<ref name=":2">Elengard T, Karlsson J, Silbernagel KG. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781873/ Aspects of treatment for posterior heel pain in young athletes.] Open Access J Sports Med. 2010; 1: 223–232.</ref>. The incidence of bilaterally is approximately 60%.<br>Common signs and symptoms:
*Posterior inferior heel pain (over the medial and lateral surface of the bone)<ref name=":2" />.
*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 (= activity-related pain)<ref name=":0" /><ref name=":1" />
*Increased pain with weight bearing, running or jumping<ref name=":0" /><ref name=":1" />
*The area often feels stiff.
*Tenderness on medial and lateral heel compression.<ref name=":3" />
*No erythema, swelling or skin changes found.<ref name=":3" />
*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" />.
*Tenderness at the insertion of the tendons (= an avascular necrosis of the arthropathy)<ref name=":1" /><ref name=":2" />.
*Limited ankle dorsiflexion range secondary to tightness of the Achilles tendon. The pain gradually resolves with rest. All the sporting activities including running should be discontinued while the child has heel pain.
*Limited ankle dorsiflexion range secondary to tightness of the Achilles tendon.
== Differential Diagnoses ==
*Hard surfaces and poor-quality or worn-out athletic shoes contribute to increased symptoms.
Posterior heel pain can occur due to
*The pain gradually resolves with rest.
* [[Achilles Tendinopathy]]
 
* [https://www.physio-pedia.com/Haglund%27s_deformity Haglund's Deformity]
Reliability or validity of methods used to obtain the ankle joint dorsiflexion or biomechanical malalignment data are not commented upon, thus reducing the quality of the data. Although pain and limping are mentioned as symptomatic traits, there have been no attempts to quantify the pain or its effect on the individual<ref name="Scharfbillig" />.<br><br>
* [[Retrocalcaneal Bursitis]]
 
* [https://physio-pedia.com/Calcaneal_Fractures?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Calcaneal stress Fracture]
== Differential Diagnosis  ==
* [https://physio-pedia.com/Calcaneal_Spurs?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Heel spur]
 
* [[Heel Fat Pad Syndrome|Heel pad syndrome]]
#Musculoskeletal causes: Achillobursitis, tenosynovitis, [[Ankle Sprain|ankle sprains]] or peritendinitis, [[Retrocalcaneal Bursitis|retrocalcaneal]] exostosis or bursitis, and [[Plantarfasciitis|plantar fasciitis]]. All these conditions should be negative to a squeeze test of the apophyseal area.  
#Infective or internal causes: [[tuberculosis]], [[Rheumatoid Arthritis|rheumatoid arthritis]], rheumatoid fever, cysts and tumors, and osteomyelitis. These cases often involve other parts of the body, so these diseases can be noticed relatively easy.
#Traumatic influences: foreign bodies, entrapment of the inferior calcaneal nerve, ruptures of tendon or ligaments, fractures and stress fractures, tarsal tunnel syndrome, and contusions.  
#Other: tarsal coalition. Decreased ROM at the subtalar joint and a negative squeeze test.<br>
 
== Diagnostic Procedures  ==
 
- 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. <br>- Ultrasonography: could show the fragmentation of secondary nucleus of ossification of the calcaneus in severs’s disease. 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">Hosgören B, Köktener A, Dilmen G: [http://www.indianpediatrics.net/aug2005/801.pdf Ultrasonography of the Calcaneus in Sever’s Disease]. Indian Pediatrics 42: 801-803, 2005. </ref>.<br> <br>
 
[[Image:X-ray voett.png|left]]  


<br>
== Diagnostic Procedures ==
[[File:Calcaneal apohysisitis.jpg|thumb]]


<br>
=== 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.


<br>  
===  Ultrasonography ===
Diagnostic Ultrasound 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>  
=== MRI ===
 
MRI showed signal changes in posterior calcaneal epiphysis, and can help localize inflammation to apophysis<ref>Idrissi MO. Sever’s disease. Sch J App Med Sci. 2021 May;5:684-5.</ref>.
Radiograph: fragmentation&nbsp;secondary nucleus<br><br>
 
[[Image:Ultrason voet.png|left]]
 
<br>
 
<br>
 
<br>
 
<br>
 
Ultrasonography: normal left heel,&nbsp;fragmentation on the right heel (arrows)<br>
== Examination  ==
== Examination  ==


*&nbsp;Tenderness and to palpation (anterior to the insertion of the Achilles tendon along the posterior border of the calcaneus).  
*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 apophystis.<br> [[Image:Squeeze test voet.png|left]]<br>
*'''[[Squeeze Test|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.
<br>
 
<br>
 
<br>
 
Squeeze test. 
 
*Standing tiptoe aggravate 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 a 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    ==


The practitioner should inform the patient and the patient’s parents that this is not a dangerous disorder and that it will resolve spontaneously as the patient matures (16-18 years old). Treatment depends on the severity of the child’s symptoms. The condition is self-limiting, thus the patient’s activity level should be limited only by pain. Treatment is quite varied.<br>() = grades of recommendation.  
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/ Modified rest or cessation of sports<ref name=":1" />.&nbsp;
*Relative Rest and/or cessation of sports<ref name=":1" />.&nbsp;
*Cryotherapy<ref name=":1" />.&nbsp;
*[[Cryotherapy]]<ref name=":1" />.
*Stretching Triceps Surae and strengthen extensors<ref name=":1" />.  
*'''Taping''': Taping the foot around the arch and heel area has been noted to reduce pain caused by Sever’s disease and ambulation.<ref name=":5" />
*Night time dorsiflexion splints (often used for plantar fasciitis, relieve the symptoms and help to maintain flexibility).  
*Silicone heel cup with medial arch support cushions the affected area for shock absorption and helps in reducing pain.
*Plantar fascial stretching.&nbsp;
*Orthoses can be prescribed to correct secondary foot malalignments, such as foot in valgus position can disrupt the [[Windlass Test|Windlass mechanism]] which is important for normal gait.<ref name=":1" />
*Gentle mobilisations to the subtalar joint and forefoot area<ref name="Leri">Leri JP: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646988/ Heel Pain in a Young Adolescent Baseball Player.] Journal of the Chiropractic Medicine 3: 66-68, 2004. </ref>  
*Stretching  of [[Triceps Surae]], Plantar fascia to improve dorsiflexion and strengthening of extensors<ref name=":1" />
*Heel lifts, Orthoses (all types, heel cups, heel foam), padding for shock absorption or strapping of heel: to decrease impact shock<ref name=":1" />.&nbsp;
*Gentle mobilizations to the subtalar joint and forefoot area<ref name="Leri">Leri JP. [https://doi.org/10.1016/S0899-3467(07)60088-3 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" />&nbsp;
*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" />
*Advise to wear supportive shoes.
*[[Therapeutic Ultrasound|Ultrasound]], nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can also be used to decrease the pain and inflammation in individuals with server's disease. <ref name=":5" />
*Ultrasound, nonsteroidal anti-inflammatory drugs.
*Casting (2-4 weeks) or Crutches (sever cases): symptom control.&nbsp;
*Corticosteroid injections are not recommended.
*Corticosteroid injections are not recommended.
*Ketoprofen Gel as an addition to treatment.
*Ketoprofen Gel as an addition to treatment.
*Taping&nbsp;<ref name=":1" />
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.


Respectable opinion and poorly conducted retrospective case series make up the majority of evidence on this condition. The level of evidence for most of what we purport to know about Sever’s disease is at such a level that prospective, well-designed studies are a necessity to allow any confidence in describing this condition and its treatment<ref name=":0" /><ref name="Scharfbillig" /><ref name=":1" /><ref name=":2" />.<br>
Symptoms usually resolve in a few weeks to 2 months after therapy is initiated<ref name=":0" /><ref name=":1" /><ref name=":2" />.  


== Resources    ==
== Resources    ==


{{#ev:youtube|A6Ffiotje2w}}<ref>David Piskulic. Case Study Sever's disease. Medbridge. Available from https://www.youtube.com/watch?v=A6Ffiotje2w</ref>
{{#ev:youtube|A6Ffiotje2w}}<ref>David Piskulic. Case Study Sever's disease. Medbridge. Available from https://www.youtube.com/watch?v=A6Ffiotje2w</ref>
 
== Complications ==
The long-term effect on the heel related to Sever's disease has not been well studied.<ref name=":5" /> There have been no long-term effects aasociated with Sever's disease. <ref name=":5" />However, the disease may reappear frequently during periods of growth and non-compliance with treatment plans, but symptoms generally resolve after the closure of the apophysis when the patient reaches skeletal maturity.<ref name=":5" /> <ref name=":4" />The following are potential complications linked to individuals suffering from this disease:
 
* Osteomyelitis<ref>Kumar S, Jain N, Karpe P, Limaye R. Osteomyelitis complicating Sever‘s disease: A report of two cases. J Clin Orthop Trauma [Internet]. 2020;11(2):310–3.</ref>
* Pain and discomfort
* Limping gait<ref>Belikan P, Färber LC, Abel F, Nowak TE, Drees P, Mattyasovszky SG. Incidence of calcaneal apophysitis ( Sever ’ s disease ) and return ‑ to ‑ play in adolescent athletes of a German youth soccer academy : a retrospective study of 10 years. J Orthop Surg Res [Internet]. 2022;9:1–6. </ref>
 
== References  ==
== References  ==


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[[Category:Foot]]
[[Category:Foot]]
[[Category:Foot - Conditions]]  [[Category:Conditions]]
[[Category:Foot - Conditions]]   
[[Category:Conditions]]
[[Category:Sports Medicine]]
[[Category:Sports Medicine]]
[[Category:Paediatrics]]
[[Category:Paediatrics]]
[[Category:Younger Athlete]]
[[Category:Younger Athlete]]
[[Category:Conditions - Paediatrics]] [[Category:Paediatrics - Conditions]]
[[Category:Paediatrics - Conditions]]  
[[Category:Paediatrics - Conditions]]

Latest revision as of 16:34, 10 August 2023

Original Editor - Tassignon Bruno Top Contributors - Tassignon Bruno, Wanda van Niekerk, Kim Jackson, Cindy John-Chu, Keta Parikh, Arnold Fredrick D'Souza, Admin, Vidya Acharya, Pacifique Dusabeyezu, Rachael Lowe, Rucha Gadgil, Shreya Pavaskar, Maarten Cnudde, Naomi O'Reilly, Claire Knott and Meaghan Rieke

Definition/Description[edit | edit source]

Heel pain.png

The term was coined by James Warren Sever in 1912. One of the most common causes of heel pain among children between the ages of 10 to 12 years. Also known as calcaneal apophysitis or calcaneoapophysitis, this condition is the painful inflammation of the calcaneal apophysis caused by repetitive microtrauma on the unossified apophysis due to traction of the achilles tendon. Other common traction injuries are Iliac apophysitis, medial epicondyle apophysitis or Little League elbow, inferior pole of patella apophysitis or Sinding-Larsen-Johansson syndrome, tibial tubercle apophysitis or Osgood-Schlatter disease, and fifth metatarsal apophysitis.

Clinically Relevant Anatomy[edit | edit source]

The calcaneal apophysis refers to the back part of the posterior aspect of the calcaneus , where the Achilles tendon inserts. This area contains the open growth plate called physis. The closure of the calcaneus growth plate typically occurs around the age of 14.[1] Until that time, new bone is forming at the calcaneal physis. When this growth plate is irritated, it undergoes stress that leads to inflammation. The primary explanation for Sever's injury involves excessive mechanical strain caused by repeated impact pressure and shear forces on the still-developing growth plate of the calcaneus.[1]

Apophysis have a higher composition of fibrocartilage. The calcaneal apophysis usually appears in children around 7-9 years old and fuses between the ages 15–17 years of age. The Achilles Tendon inserts to the lower, posterior and slightly medial aspect of the calcaneus. The calcaneal growth plates are subjected to high stress from the plantar aponeurosis and the Achilles tendon.[2]

Etiology/Risk Factors[edit | edit source]

Sever’s disease is an osteochondrosis caused by overload. This C-shaped growth zone becomes inflamed secondary to repetitive traction stress of the Achilles tendon.

Risk factors may include:

  • High physical and sporting activities especially those involving repetitive running and jumping
  • Heel cord tightness
  • Weak ankle dorsiflexion
  • Poorly cushioned or worn out athletic shoes
  • Running on hard surfaces
  • Biomechanical factors such as genu varum, forefront pes cavovarus or pes planus[3][4]
  • Obesity[5]
  • Greater waist circumference and increased height[5]

Epidemiology[edit | edit source]

Sever's disease is an overgrowth syndrome similar to Osgood-Schlatter disease. Growth is directly proportional to the amount of stress placed on the calcaneal growth plates.

Active children and adolescents, 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[6][7]. This disease occurs most commonly during the early part of the growth spurt. A boy-to-girl ratio is 2-3:1.[7] It occurs only in the growing children and never occurs after puberty[8].

Characteristics/Clinical Presentation[edit | edit source]

Anklesqueezetest.jpg

This syndrome can occur unilaterally or bilaterally[9]. The incidence of bilaterally is approximately 60%[3].
Common signs and symptoms:

  • Pain is usually absent when the child gets up in the morning[7].
  • Increased pain with weight bearing, running or jumping[6][7]
  • Tenderness on medial and lateral heel compression.[8]
  • No erythema, swelling or skin changes found.[8]
  • Can be associated with other foot malalignments.
  • The child may limp at the end of physical activity[2][7].
  • Limited ankle dorsiflexion range secondary to tightness of the Achilles tendon. The pain gradually resolves with rest. All the sporting activities including running should be discontinued while the child has heel pain.

Differential Diagnoses[edit | edit source]

Posterior heel pain can occur due to

Diagnostic Procedures[edit | edit source]

Calcaneal apohysisitis.jpg

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]

Diagnostic Ultrasound 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[10].

MRI[edit | edit source]

MRI showed signal changes in posterior calcaneal epiphysis, and can help localize inflammation to apophysis[11].

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[2]. 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[7]. 
  • Cryotherapy[7].
  • Taping: Taping the foot around the arch and heel area has been noted to reduce pain caused by Sever’s disease and ambulation.[1]
  • 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.[7]
  • Stretching of Triceps Surae, Plantar fascia to improve dorsiflexion and strengthening of extensors[7]
  • Gentle mobilizations to the subtalar joint and forefoot area[12]
  • 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[12]
  • Ultrasound, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can also be used to decrease the pain and inflammation in individuals with server's disease. [1]
  • 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[6][7][9].

Resources[edit | edit source]

[13]

Complications[edit | edit source]

The long-term effect on the heel related to Sever's disease has not been well studied.[1] There have been no long-term effects aasociated with Sever's disease. [1]However, the disease may reappear frequently during periods of growth and non-compliance with treatment plans, but symptoms generally resolve after the closure of the apophysis when the patient reaches skeletal maturity.[1] [3]The following are potential complications linked to individuals suffering from this disease:

  • Osteomyelitis[14]
  • Pain and discomfort
  • Limping gait[15]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Ramponi DR, Baker C. Sever’s Disease (Calcaneal Apophysitis). Adv Emerg Nurs J. 2019;41(1):10–4.
  2. ↑ 2.0 2.1 2.2 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.
  3. ↑ 3.0 3.1 3.2 Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021
  4. ↑ McSweeney SC, Reed L, Wearing S. Foot Mobility Magnitude and Stiffness in Children With and Without Calcaneal Apophysitis. Foot Ankle Int. 2018 May;39(5):585-590.
  5. ↑ 5.0 5.1 James AM, Williams CM, Luscombe M, Hunter R, Haines TP. Factors Associated with Pain Severity in Children with Calcaneal Apophysitis (Sever Disease). J Pediatr [Internet]. 2015;167(2):455–9.
  6. ↑ 6.0 6.1 6.2 Launay F. Sports-related overuse injuries in children. Orthopaedics & Traumatology: Surgery & Research. 2015 Feb 1;101(1):S139-47.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 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.
  8. ↑ 8.0 8.1 8.2 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.
  9. ↑ 9.0 9.1 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.
  10. ↑ Hosgoren B, Koktener A, Dilmen G. Ultrasonography of the calcaneus in Sever's disease. Indian pediatrics. 2005 Aug 1;42(8):801.
  11. ↑ Idrissi MO. Sever’s disease. Sch J App Med Sci. 2021 May;5:684-5.
  12. ↑ 12.0 12.1 Leri JP. Heel pain in a young adolescent baseball player. Journal of Chiropractic Medicine. 2004 Mar 1;3(2):66-8.
  13. ↑ David Piskulic. Case Study Sever's disease. Medbridge. Available from https://www.youtube.com/watch?v=A6Ffiotje2w
  14. ↑ Kumar S, Jain N, Karpe P, Limaye R. Osteomyelitis complicating Sever‘s disease: A report of two cases. J Clin Orthop Trauma [Internet]. 2020;11(2):310–3.
  15. ↑ Belikan P, Färber LC, Abel F, Nowak TE, Drees P, Mattyasovszky SG. Incidence of calcaneal apophysitis ( Sever ’ s disease ) and return ‑ to ‑ play in adolescent athletes of a German youth soccer academy : a retrospective study of 10 years. J Orthop Surg Res [Internet]. 2022;9:1–6.
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