by Allan Strongwater, MD, FAOA
Sever's (Sever) Disease is also known as Calcaneal apophysitis.
Sever's disease is an inflammation of the apophysis (growth plate) of the calcaneus. It is the most common cause of isolated heel pain in children and affects males more often than females. Sever's disease tends to occur most commonly during periods of rapid growth, 10-16 years of age in males and 9-14 years in females.
Signs and Symptoms
The primary clinical presentation of Sever's disease is calcaneal heel pain that tends to increase with increasing levels of repetitive loading of the apophysis such as found in running, jumping or rapid walking. The pain subsides with rest but often returns with increased activity.
In more severe forms of calcaneal apophysitis classical signs of inflammation can be found such as swelling around the calcaneal tuberosity with redness and tenderness. Sever's disease may occur unilaterally or bilaterally.
In most cases, the diagnosis can be made through a careful history of localized heel pain exacerbated by repetitive running, jumping or walking. Physical examination usually demonstrates difficulty of the child's ability to toe walk on the affected side due to increased pain. Pressure from the examining finger applied to the calcaneal apophysis at the point of insertion of the heel cord usually elicits pain.
Radiographs of the calcaneus, in Sever's disease, are usually normal for the child's age. Bone scan and other advanced forms of imaging are usually not indicated for Sever's disease. However, be advised a number of benign and malignant tumors do occur in the body of the calcaneus in children. Careful history and physical exam can help delineate the pain syndrome.
By in large, Sever's disease is a self-limited disorder. Its degree of severity may vary in relation to level of repetitive activity, but the disease usually resolves rapidly once the calcaneal apophysis closes and the bone fuses to the main body of the calcaneus. Therefore, treatment is usually supportive. The following have been found helpful in relieving the pain:
Reduction adjustment in running, jumping and long rapid periods of walking
Taping the heel during the above activities, or use of various ankle braces or shoe inserts.
Heel cord stretching exercises.
Use of non-flat shoes, that is a shoe with a small heel, or heel lift inside the shoe.
Acutely, intermittent use of ice to the calcaneus provides symptomatic pain relief.
Medications that reduce inflammation such as ibuprofen or naproxen may be helpful in more severe cases.
In very severe cases of Calcaneal apophysis, a cast or walking boot may be required for 6 to 12 weeks, followed by appropriate post immobilization rehabilitation.
Overall, the prognosis of Sever's Disease is excellent.
Nearly all cases of Sever's Disease spontaneously resolve upon closure of the calcaneal apophysis. However, during the growing period, the severity of Sever's Disease may wax and wane especially in children who are athletically active and during periods of rapid growth.
Causes and Risk Factors
Sever's Disease is a calcaneal apophysitis usually resulting from repetitive loading of the apophysis. Therefore it can be classified as an over-use syndrome that tends to occur in athletically active children.
Flat shoes, or non-supportive shoes may contribute to the risk of development of Sever's Disease.
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