Overview
Definition:
Sever's disease, also known as calcaneal apophysitis, is an inflammation of the growth plate (apophysis) of the calcaneus (heel bone)
It is a common cause of heel pain in skeletally immature individuals, typically occurring during periods of rapid growth
The condition results from repetitive stress and traction on the apophysis by the Achilles tendon, leading to microtrauma and subsequent inflammation.
Epidemiology:
Sever's disease is most common in children aged 8 to 14 years, with a slight predominance in boys
It typically affects active children involved in sports that involve running and jumping
Bilateral involvement occurs in approximately 60% of cases
The incidence is not precisely documented but is considered a frequent cause of pediatric foot pain.
Clinical Significance:
Understanding and effectively managing Sever's disease is crucial for pediatricians and orthopedic specialists to alleviate pain, restore normal function, and prevent long-term sequelae
Prompt diagnosis and appropriate conservative management can significantly improve a child's quality of life and participation in physical activities, impacting their physical and psychosocial development.
Clinical Presentation
Symptoms:
Insidious onset of heel pain, typically bilateral
Pain is exacerbated by activity, especially running and jumping
Pain is often worse at the end of the day or after physical exertion
Tenderness to palpation over the posterior aspect of the calcaneus, at the insertion of the Achilles tendon
Limping may be present, particularly after rest or upon initiating activity
Reluctance to participate in sports or physical activities.
Signs:
Tenderness to direct palpation over the calcaneal apophysis
Pain elicited with passive dorsiflexion of the foot, which stretches the gastrocnemius-soleus complex and compresses the apophysis
Squeezing the heel from the sides may reproduce pain in some cases
Normal gait, but may exhibit a protective limp
No significant swelling or erythema is typically observed, differentiating it from other inflammatory conditions.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on a history of activity-related heel pain and physical examination findings in a skeletally immature child
Radiographic findings are not always necessary but can support the diagnosis
Characteristic X-ray findings may include widening of the apophyseal space, fragmentation, or increased density of the apophysis
These are often considered normal variations of skeletal maturation and should be interpreted in the context of clinical findings.
Diagnostic Approach
History Taking:
Detailed history of pain onset, location, duration, and aggravating/relieving factors
Inquiry about recent growth spurts, increase in physical activity, or participation in new sports
Questions regarding footwear and any changes
Rule out any history of trauma to the heel
Assess the impact of pain on daily activities and schooling.
Physical Examination:
Palpate the entire calcaneus, focusing on the posterior aspect and the insertion of the Achilles tendon for tenderness
Assess range of motion of the ankle and foot, noting any pain with passive dorsiflexion and plantarflexion
Evaluate for tightness of the gastrocnemius-soleus complex
Examine footwear for adequacy and wear patterns
Observe gait for limping or antalgic patterns.
Investigations:
Radiographs (X-rays) of the foot and ankle are usually not required for diagnosis but can be useful to rule out other conditions such as fractures, osteomyelitis, or tumors
If performed, X-rays may show apophyseal widening, fragmentation, or sclerosis
MRI is rarely indicated unless there is suspicion of other pathology
Laboratory tests are generally not necessary for uncomplicated Sever's disease.
Differential Diagnosis:
Other causes of heel pain in children include plantar fasciitis, calcaneal stress fracture, Achilles tendinopathy, heel pad syndrome, calcaneal cysts, foreign body, and systemic inflammatory conditions (e.g., juvenile idiopathic arthritis)
It is important to differentiate from these conditions based on the clinical presentation and, if necessary, investigations.
Management
Initial Management:
Activity modification is the cornerstone of treatment
This involves reducing or temporarily stopping high-impact activities such as running, jumping, and sports that exacerbate the pain
Encouraging low-impact activities like swimming or cycling can help maintain fitness without aggravating the condition
Rest is crucial for the inflamed apophysis to heal.
Medical Management:
Pain management can be achieved with over-the-counter analgesics such as acetaminophen (paracetamol) or non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
NSAIDs should be used judiciously and for short durations due to potential gastrointestinal side effects in children
Doses should be age and weight-appropriate, e.g., ibuprofen 5-10 mg/kg/dose every 6-8 hours or paracetamol 10-15 mg/kg/dose every 4-6 hours.
Supportive Care:
Stretching exercises for the gastrocnemius and soleus muscles are vital to reduce tension on the calcaneal apophysis
Exercises should be performed gently and regularly
Footwear modifications, such as wearing supportive shoes with good cushioning, can reduce impact
Heel cups or orthotic inserts can provide additional support and shock absorption
In some cases, a temporary heel lift may be beneficial.
Surgical Management:
Surgical intervention is rarely necessary for Sever's disease
It is typically reserved for severe, recalcitrant cases that have failed to respond to conservative management for an extended period (e.g., 6-12 months) and significantly impair daily function
Surgical options are generally not well-defined and may include procedures to release the Achilles tendon or address apophyseal abnormalities, but these are considered a last resort.
Complications
Early Complications:
Persistent pain that interferes with daily activities and sports
Worsening limp
Psychological distress due to limitations in physical activity
Minor issues like skin irritation from orthotics.
Late Complications:
Chronic heel pain is uncommon if managed appropriately
In rare cases, if growth plate damage is significant or prolonged, it could theoretically lead to subtle deformities or persistent pain, though this is exceptionally rare for Sever's disease
The apophysis usually fuses with the calcaneus, and symptoms resolve with skeletal maturity.
Prevention Strategies:
Adequate warm-up and cool-down routines before and after sports activities
Gradual increase in training intensity and duration to avoid sudden overload
Proper footwear selection and replacement when worn out
Regular stretching of the calf muscles, especially during growth spurts
Educating young athletes and parents about the condition and the importance of rest and activity modification.
Prognosis
Factors Affecting Prognosis:
Adherence to activity modification and conservative treatment recommendations
Severity of initial symptoms and degree of inflammation
Age of the child at presentation (younger children may have longer durations of symptoms)
Presence of tight calf muscles.
Outcomes:
The prognosis for Sever's disease is generally excellent
Symptoms typically resolve spontaneously with skeletal maturity as the calcaneal apophysis fuses with the calcaneus
This usually occurs within 1-2 years after the onset of symptoms, or by late adolescence
Most children can return to full activity without long-term consequences.
Follow Up:
Follow-up is usually not required if symptoms are improving with conservative management
However, regular check-ins may be beneficial for children with severe symptoms or poor compliance
Continued education on stretching and activity modification is important throughout the symptomatic period
Re-evaluation is warranted if symptoms worsen or do not improve as expected, to rule out other diagnoses.
Key Points
Exam Focus:
Sever's disease is a traction apophysitis of the calcaneal growth plate
Primarily a clinical diagnosis in active children aged 8-14
Characterized by activity-related heel pain and tenderness over the posterior calcaneus
Management is conservative: rest, activity modification, stretching, and NSAIDs for pain relief
Prognosis is excellent with spontaneous resolution at skeletal maturity.
Clinical Pearls:
Always consider Sever's disease in a child presenting with heel pain during activity
Palpation of the calcaneal apophysis is the most reliable physical finding
Differentiate from plantar fasciitis (pain more anterior/medial) and stress fractures (often point tenderness and may have X-ray findings)
Emphasize to parents that it's a condition of growth, not a serious injury.
Common Mistakes:
Over-reliance on imaging when the diagnosis is clinical
Prescribing prolonged rest when activity modification is more appropriate
Inadequate patient and parent education regarding the self-limiting nature and management of the condition
Ignoring calf tightness as a contributing factor
Failing to consider alternative diagnoses in atypical presentations.