Cath Lab Digest

Given that calcaneal apophysitis is a common cause of heel pain in children, this author reviews the literature and offers insights on the etiology of the condition, the diagnostic workup and pertinent treatment pearls.

   Calcaneal apophysitis is a traction apophysitis of the insertion of the Achilles tendon into the calcaneus.¹ In 1912, Sever noted this condition is not unusual in growing children but one would never encounter it after the child reaches puberty. Sever considered the condition to be a muscle strain and suggested rest and protection to resolve the condition. He did not say that calcaneal apophysitis was an osteochondrosis although other authors have classified it as such.^2-4

   Although this condition was once considered a true osteochondritis, it is now generally agreed that this condition is a mechanical overuse syndrome with a self-limited, benign prognosis.⁵ Calcaneal apophysitis is an overuse syndrome. It is analogous to tibial tubercle apophysitis, a condition also known as Osgood-Schlatter disease.⁶ Other common traction injuries that may be similar include injuries to the medial epicondyle, iliac apophysis and the inferior pole of the patella and fifth metatarsal base.⁷

   One study focused on 3,805 injuries that occurred over two seasons of youth football (soccer) leagues in Britain. Researchers found that growth-related injuries, including Sever’s disease and Osgood-Schlatter’s disease, accounted for 5 percent of total injuries, peaking in the under-11 age group for Sever’s disease.⁸

   Calcaneal apophysitis is most common in boys ages 10 to 12 who are active in sports.⁹ However, with the rise in sports participation by girls, calcaneal apophysitis is believed to occur more frequently in girls ages 8 to 10.7 In one study of 85 patients with calcaneal apophysitis, 75 percent of patients were male.¹⁰

   Specific sports that have been frequently associated with this condition include soccer, gymnastics, football, baseball, ice hockey, tennis, figure skating, ballet, tae kwon do and various running sports.¹¹

   A 2008 retrospective study by Lau and colleagues focused on 506 pediatric patients diagnosed with sports-related overuse injuries over a study period of five years and seven months.¹² Researchers diagnosed apophysitis in 32.4 percent (164 patients) at the mean age of 9.9 years. This was the youngest mean age of diagnosis of any of the conditions the researchers reported. In this study, 61 percent of those patients with apophysitis had bilateral symptoms.

   In the critical review of the literature, Scharfbillig and co-workers state that “although the literature contains a fairly large number of studies that have reported the incidence of Sever’s disease, the lack of consistency in reporting, use of multiple raters, and retrospective analysis of notes reduce the confidence with which the findings can be accepted.”¹³

A Closer Look At Etiological Triggers

   The most common cause of calcaneal apophysitis is believed to be repetitive microtrauma or overuse, which leads to injury and symptomatology at the apophysis.¹⁰ Apophyses have a higher composition of fibrocartilage than epiphyses. Epiphyses are composed of more hyaline cartilage and are subjected to more axial load.

   Volpon and colleagues conducted a study with 69 patients with apophysitis and 392 normal children with no symptoms.¹⁴ They reported that the most significant differences in the calcaneal X-rays of the two groups was a greater degree of fragmentation of the apophysis. The authors concluded that the greater degree of fragmentation suggests a mechanical etiology for apophysitis.