Sever's Disease

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Original Editors

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Search Strategy

To collect some information about this topic, I searched the Web of Knowledge database, the PeDro database and the Pubmed database. The main keywords I used were: Sever’s Disease, Calcaneal Apophysitis, physiotherapy, physical therapy, diagnosis, treatment, rehabilitation (often a combination of keywords). I also consulted books for my research (resources).
Most successful keywords: Sever’s Disease; Calcaneal Apophysitis; treatment; physical therapy.
Keyword combinations: Sever’s Disease treatment ; Calcaneal Apophysitis treatment; physical therapy calcaneal apophysitis.

Definition/Description

Sever’s disease, also known as calcaneal apophysitis or Osgood-Schlatter syndrome of the foot. This traction apophysitis is secondary to repetitive microtraumata or overuse of the heel in young athletes. [1]

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. [2]

File:Voet apophyse.png

[2]

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. Calcaneal apophysitis is a common injury in young athletes and is believed to be caused by running and jumping.
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. This disease occurs most commonly during the early part of the growth spurt. A boy-to-girl ratio is 2-3:1.
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. [2]

Characteristics/Clinical Presentation

This syndrome can occur unilaterally or bilaterally. The incidence of bilaterally is approximately 60%. [3]
Common signs and symptoms:
- Posterior inferior heel pain (over the medial and lateral surface of the bone).
- Pain is usually absent when the child gets up in the morning.
- Increased pain with weight bearing, running or jumping (= activity-related pain).
- The area often feels stiff.
- The child may limp at the end of physical activity. [2]
- Tenderness at the insertion of the tendons (= an avascular necrosis of the arthropathy).
- 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.

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. [2]

Differential Diagnosis

1. Musculoskeletal causes: Achillobursitis, tenosynovitis, ankle sprains or peritendinitis, retrocalcaneal exostosis or bursitis, and plantar fasciitis. All these conditions should be negative to a squeeze test of the apophyseal area.
2.  Infective or internal causes: tuberculosis, 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.
3. Traumatic influences: foreign bodies, entrapment of the inferior calcaneal nerve, ruptures of tendon or ligaments, fractures and stress fractures, tarsal tunnel syndrome, and contusions.
4. Other: tarsal coalition. Decreased ROM at the subtalar joint and a negative squeeze test.
   

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.
- 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 tendinitis and/or retrocalcaneal bursitis . [4]

File:X-ray voett.png

Radiograph: fragmentation secondary nucleus

File:Ultrason voet.png

Ultrasonography: normal left heel, fragmentation on the right heel (arrows)

Outcome Measures

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Examination

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Physical Therapy Management

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Key Research

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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