Practical Pointers On Treating Sever’s Disease In Young Athletes
Complete immobilization using a below-knee cast can be harsh to the psyche of the young athlete and harsh physically on extremity musculature. A superior approach is to allow protective weightbearing with a controlled ankle motion (CAM) walker and crutches (if necessary) during the acute phase for two to three weeks.7 One can prescribe analgesics such as non-steroidal anti-inflammatory medications (NSAIDs) at this time as necessary along with daily icing to the affected heel. This initial period of treatment can be referred to as “rest and recovery.”
After two to three weeks, the young athlete should show clinical signs of either diminished pain or elimination of pain upon the “squeeze test” of the heel. At this point, treatment should focus on the following: increasing the strength of the young athlete and improving the biomechanical factors that contributed to the calcaneal apophysitis.
First, to avoid disuse atrophy, allow the patient to perform low-impact exercises such as the use of a stationary bike (at low resistance) and swimming. You can allow walking at a treadmill at low speed but only if you first fit the patient for a heel lift for a shoe with a rigid heel counter and adequate shock absorption. Therefore, it is good clinical practice to evaluate the young athlete’s shoe gear at this point of treatment.
Secondly, institute a daily stretching regimen to address the ankle equinus. It is important to demonstrate the stretching instructions to the parents and/or coaches. Patients can perform stretching using a towel, belt or elastic stretching band two to three times daily. One can also dispense a dorsiflexory night splint for the patient to wear one hour daily for each limb if adherence to the stretching regimen is a concern.
After two to three weeks of following the “stretching and strengthening” protocol, the young athlete should exhibit signs of complete relief. Fabricate orthotics with deep heel cups and a vertical rearfoot posting for added motion control of the calcaneus. Furthermore, one should utilize heel lifts, which can be built into the orthotic device, to decrease the strain on the Achilles tendon. The orthotic device may need to be customized for particular performance shoes such as cleats. Instruct the patient and parents to bring the shoes into the office for evaluation prior to giving medical clearance for the young athlete to return to sports.
If the patient is still symptomatic at this point of treatment, physical therapy may be necessary with a sports therapist for an additional three weeks. At this point, there is clinical reasoning to order an MRI to evaluate other plausible causes of heel pain.
Calcaneal apophysitis can be a painful and debilitating condition for the young athlete. From the clinical standpoint, diagnosis should primarily be based on clinical findings and only reinforced with radiographic measures. The treatment follows a pattern that is common practice in sports medicine. There is a period of “rest and recovery” followed by a period of “stretching and strengthening.” Keep in mind that most young athletes are able to return to their respective sports after a period of four to eight weeks.
Clinicians have the role of educating the coaches and parents that calcaneal apophysitis is an overuse injury that can be prevented. More children are participating in school sports and at a competitive level. Accordingly, parents should proceed with caution when their rapidly growing child is involved in multiple sports throughout the course of a year.
Dr. Basra is an Associate of the American College of Foot and Ankle Surgeons. He is in private practice at Active Foot and Ankle Care in Fair Lawn, N.J., and is a consulting team physician for Montclair State University. Dr. Basra is also a clinical instructor at New York Methodist Hospital in Brooklyn, N.Y.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.