Practical Pointers On Treating Sever’s Disease In Young Athletes

Suneel Basra, DPM, AACFAS

There are several causes of heel pain in the young athletic population with the most common being calcaneal apophysitis (also referred to as Sever’s disease). Sever first reported calcaneal apophysitis in 1912 as an inflammation of the apophysis, causing discomfort to the heel, mild swelling and difficulty walking in growing children.1

   The condition usually manifests between the ages of 8 and 14 with a higher incidence in boys than girls. In reality, however, calcaneal apophysitis is being diagnosed more frequently in girls due to their increase in participating in sports such as soccer, basketball and softball.

   There are many biomechanical factors that predispose a young athlete to calcaneal apophysitis. The majority of patients will present with an ankle equinus deformity, which ultimately exerts an increased pulling force to the Achilles insertion and non-ossified apophysis.2 Furthermore, patients may present with hyperpronation of the rearfoot. This allows more of a “teeter-totter” effect or lack of motion control on the frontal plane of the calcaneus. Treatment goals should focus on improving these biomechanical factors while the young athlete is undergoing skeletal maturation.

Pertinent Diagnostic Insights

The clinical presentation of calcaneal apophysitis will include posterior heel pain on medial and lateral compression. This is commonly referred to as the “squeeze test.” The young athlete may complain of pain to either one or both heels when walking or running, and at times during weightbearing after a period of rest. Patients may also describe a dull, achy pain to the heel with the absence of clinical swelling, redness or ecchymosis with dorsiflexion of the ankle. It is important to interview individuals (including parents, coaches and trainers) involved in the care of the young athlete in order to determine whether the patient has elicited any forms of compensation for the injury. These compensations can include toe-walking/running, early heel lift and limping.3

   Some authors have reported the condition to be an osteochondritis of the calcaneus while others have attributed the ailment to a “mechanical overuse syndrome.”4 Do not use plain film X-rays to definitively diagnose calcaneal apophysitis but rather to aid in ruling out any other causes of posterior heel pain such as calcaneal stress fracture, bone cyst, neoplasm or even a foreign body. It is beneficial to perform bilateral X-rays to compare any subtle differences between the pathologic and non-pathologic foot.

   A study conducted by Volpon and colleagues described the key radiographic finding for calcaneal apophysitis to be fragmentation of the apophysis.5 This “fragmentation” hypothesis was due to microtrauma and overuse of the posterior heel segment. Recent magnetic resonance imaging (MRI) studies have attempted to help understand the exact anatomic location of injury. Ogden and colleagues analyzed MRI findings to determine that the injury could be due to a metaphyseal stress fracture adjacent to the apophysis.6 One should diagnose calcaneal apophysitis by clinical findings. An MRI is rarely required.

Keys To Addressing Pain And Correcting Biomechanics

It is imperative to reassure the caretakers of the young athlete that calcaneal apophysitis is a self-limiting disease. Avoid the term “disease” when discussing the condition with parents and use terms such as “growth plate swelling” to ease the anxiety of the diagnosis. As is the case with most sports-related injuries, rest and reduction of pain are the keys to the patient’s return to sports.

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