Sever Disease/Calcaneal Apophysitis
Stephen Simons
Jeff Kindred
BasicsDescription
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Sever disease, also known as calcaneal apophysitis, is an overuse syndrome causing late childhood and adolescent heel pain.
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This traction apophysitis is the foot equivalent to Osgood-Schlatter disease.
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Synonym(s): Calcaneal apophysitis
Epidemiology
Incidence
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Typically occurs during an adolescent growth spurt
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Predominant age: Described most often between the ages of 9 and 12 yrs; most frequent at age 11 in girls and at age 12 in boys
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Predominant gender: Male > Female
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Occurs bilaterally in just over 60% of cases
Risk Factors
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Adolescent growth spurt
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Increased or excessive sport and play activity
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Tight gastrocsoleus complex
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Weak ankle dorsiflexors
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Biomechanical factors such as genu varum and forefoot varus
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Poor-quality or worn-out athletic shoes
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Poorly cushioned or low-heeled shoes such as soccer, baseball, track, or cycling cleats
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Running on hard surfaces
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High-impact sports
Etiology
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The posterior calcaneus develops as a secondary ossification center.
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This secondary ossification center provides attachment for the tendoachilles.
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This secondary ossification site is not contiguous with a diarthrodial joint; therefore, this portion of bone is called an apophysis instead of an epiphysis.
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A physis (open growth plate) separates the apophysis from the body of the calcaneus.
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The calcaneal physis typically closes between the ages of 12 and 15 yrs.
DiagnosisHistory
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An 8–13-yr-old child presents with heel pain worsened with increased activity (1)[C].
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Recent growth spurt coincides with vigorous sport or play activities (1)[C].
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Sports requiring a lot of running and jumping activities are particularly prone to cause this overuse syndrome (2)[C].
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Pain can be unilateral or bilateral and is relieved with rest (2)[C].
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The pain may become severe enough to stop sport activity and even require crutch walking (2)[C].
Physical Exam
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Signs and symptoms include:
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Intermittent or continuous posterior heel pain during or following increased sport or play activity (1)[C]
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Pain can be bilateral or unilateral (1)[C].
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Pain is usually absent in the morning.
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No swelling
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No ecchymoses or skin changes
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Physical examination includes the following:
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Absence of swelling or erythema
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Tenderness just anterior to the Achilles insertion on the heel (2)[C]
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Tenderness with medial and lateral compression of the heel to the posterior 3rd of the calcaneus (2)[C]
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Pain aggravated by standing on tiptoe (Sever sign)
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Heel cord inflexibility with sometimes <10 degrees of dorsiflexion
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Biomechanical contributors such as forefoot varus, hallux valgus, pes cavus, and pes planus (1)[C]
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Diagnostic Tests & Interpretation
Imaging
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Radiographs may show fragmentation, sclerosis, and increased density of the apophysis, but these radiographic changes can be normal (2,3)[C].
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Imaging is not necessary to make this clinical diagnosis but may be helpful to rule out other causes of heel pain (2)[C].
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MRI has been used to evaluate persistent heel pain that does not respond to conservative treatment and has shown many of these patients to have bone bruising and edema on the calcaneal metaphysis and apophysis (4)[C].
Differential Diagnosis
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Calcaneal bursitis
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Insertional Achilles tendonitis
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Fat pad syndrome
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Plantar fasciitis
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Calcaneal stress fracture
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Tarsal tunnel syndrome
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Tarsal coalition
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Calcaneal osteomyelitis
P.533
Treatment-
Rest or reduce activity to a pain tolerance level (2,3)[C].
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Ice (2,3)[C]
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NSAIDs for pain control (2,3)[C]
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Heel lifts (2,3)[C]
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Viscoelastic heel cups (2,3)[C]
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If not responsive to conservative treatment, a short-leg cast or boot walker or even immobilization may be necessary (2,4)[C].
Additional Treatment
Additional Therapies
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Gastrocsoleus stretching exercises: Knee straight and knee flexed stretch with the heel maintained on the floor or ground (2)[C]
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Strengthening of the quadriceps and gastrocsoleus to better equip these muscle groups to act as shock absorbers (2)[C]
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Strengthening of the foot dorsiflexors
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Shoe orthotics may be helpful to correct significant biomechanical abnormalities. Off-the-shelf orthoses are much more cost-effective and can be tried 1st before custom orthoses are considered.
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Good-quality shoe with adequate shock absorption and firm heel counter (2)[C]
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Time to symptom resolution varies, but symptoms abate totally with skeletal maturity (2)[C].
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No reports of long-term sequelae from Sever disease (2)[C]
Surgery/Other Procedures
Not indicated
Ongoing CareFollow-Up Recommendations
Referral/disposition necessary only when clinician is uncertain of diagnosis
Complications
Persistent pain that does not respond to conservative measures may indicate there is a calcaneal stress fracture and may require a 3–4-wk period of immobilization (4)[C].
References
1. Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987;7:34–38.
2. Hendrix CL. Calcaneal apophysitis (Sever disease). Clin Podiatr Med Surg North Am. 2005;22:55–62, vi.
3. Cassas KJ, Cassettari-Wayhs A. Childhood and adolescent sports-related overuse injuries. Am Fam Physician. 2006;73:1014–1022.
4. Ogden JA, Ganey TM, Hill JD, et al. Sever's injury: a stress fracture of the immature calcaneal metaphysis. J Pediatr Orthop. 2004;24:488–492.
Additional Reading
Madden CC, Mellion MB. Sever's disease and other causes of heel pain in adolescents. Am Fam Physician. 1996;54:1995–2000.
Stanitski CL. Pediatric and adolescent sports injuries. Clin Sports Med. 1997;16:613–633.
CodesICD9
732.5 Juvenile osteochondrosis of foot
Clinical Pearls
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Total rest may hasten the recovery from this heel pain but may not be necessary. Reducing the amount of activity may allow sports participation without worsening the heel pain.
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Current evidence does not suggest any long-term sequelae.