Sever Disease/Calcaneal Apophysitis

Ovid: 5-Minute Sports Medicine Consult, The

Sever Disease/Calcaneal Apophysitis
Stephen Simons
Jeff Kindred
  • Sever disease, also known as calcaneal apophysitis, is an overuse syndrome causing late childhood and adolescent heel pain.
  • This traction apophysitis is the foot equivalent to Osgood-Schlatter disease.
  • Synonym(s): Calcaneal apophysitis
  • Typically occurs during an adolescent growth spurt
  • 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
  • Predominant gender: Male > Female
  • Occurs bilaterally in just over 60% of cases
Risk Factors
  • Adolescent growth spurt
  • Increased or excessive sport and play activity
  • Tight gastrocsoleus complex
  • Weak ankle dorsiflexors
  • Biomechanical factors such as genu varum and forefoot varus
  • Poor-quality or worn-out athletic shoes
  • Poorly cushioned or low-heeled shoes such as soccer, baseball, track, or cycling cleats
  • Running on hard surfaces
  • High-impact sports
  • The posterior calcaneus develops as a secondary ossification center.
  • This secondary ossification center provides attachment for the tendoachilles.
  • This secondary ossification site is not contiguous with a diarthrodial joint; therefore, this portion of bone is called an apophysis instead of an epiphysis.
  • A physis (open growth plate) separates the apophysis from the body of the calcaneus.
  • The calcaneal physis typically closes between the ages of 12 and 15 yrs.
  • An 8–13-yr-old child presents with heel pain worsened with increased activity (1)[C].
  • Recent growth spurt coincides with vigorous sport or play activities (1)[C].
  • Sports requiring a lot of running and jumping activities are particularly prone to cause this overuse syndrome (2)[C].
  • Pain can be unilateral or bilateral and is relieved with rest (2)[C].
  • The pain may become severe enough to stop sport activity and even require crutch walking (2)[C].
Physical Exam
  • Signs and symptoms include:
    • Intermittent or continuous posterior heel pain during or following increased sport or play activity (1)[C]
    • Pain can be bilateral or unilateral (1)[C].
    • Pain is usually absent in the morning.
    • No swelling
    • No ecchymoses or skin changes
  • Physical examination includes the following:
    • Absence of swelling or erythema
    • Tenderness just anterior to the Achilles insertion on the heel (2)[C]
    • Tenderness with medial and lateral compression of the heel to the posterior 3rd of the calcaneus (2)[C]
    • Pain aggravated by standing on tiptoe (Sever sign)
    • Heel cord inflexibility with sometimes <10 degrees of dorsiflexion
    • Biomechanical contributors such as forefoot varus, hallux valgus, pes cavus, and pes planus (1)[C]
Diagnostic Tests & Interpretation
  • Radiographs may show fragmentation, sclerosis, and increased density of the apophysis, but these radiographic changes can be normal (2,3)[C].
  • Imaging is not necessary to make this clinical diagnosis but may be helpful to rule out other causes of heel pain (2)[C].
  • 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
  • Calcaneal bursitis
  • Insertional Achilles tendonitis
  • Fat pad syndrome
  • Plantar fasciitis
  • Calcaneal stress fracture
  • Tarsal tunnel syndrome
  • Tarsal coalition
  • Calcaneal osteomyelitis


Ongoing Care
Follow-Up Recommendations
Referral/disposition necessary only when clinician is uncertain of diagnosis
732.5 Juvenile osteochondrosis of foot

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