Sever’s disease (also known as calcaneal apophysitis) is one of the most common causes of heel pain in growing children and adolescents. It is an inflammation of the growth plate in the calcaneus (heel) bone.
Sever’s disease is caused by repetitive stress to the heel, and most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly.
Children and adolescents who participate in athletics—especially running and jumping sports—are at an increased risk for this condition. However, less active adolescents may also experience this problem, due to poor biomechanics in the foot such as flat feet.
The calcaneus is situated at the most posterior (back) aspect of the foot. The large Achilles tendon (distal insertion of the calf muscles) inserts onto the lower, posterior and slightly medial aspect of the calcaneus.
The plantar fascia originates from the medial tubercle on the plantar aspect of the calcaneus. Proximal to the epiphysis is the apophysis, where the Achilles tendon actually inserts. The calcaneal growth plate and apophysis are situated in an area subject to high stress from the plantar and Achilles tendons. When a child is fully grown the growth plates close and are replaced by solid bone. Until this occurs, the growth plates are weaker and are vulnerable to trauma.
Severs disease is a ‘traction apophysitis’ caused by excessive stress being placed on a growth plate by tight tendons. In the growing body long bones, in this case the tibia and fibula of the lower leg, can increase in length very quickly.
The musculo-tendinous unit in the area takes longer to adapt to the new length of the bone and this places excessive strain on the bone at the distal insertion of the muscle. This is accentuated in people who engage in high levels of activity, where muscle tightness is more common.
In some cases, both heels will have symptoms, although one heel may be worse than the other. Symptoms may include: Pain and tenderness under the heel, swelling at the heel, that can be aggravated by activity or by just standing on the toes.
Sever’s disease can be diagnosed by investigating the subjective and objective history of the symptoms and looking at the childs activity levels. The main special test performed is the ‘squeeze test’: where the medial and lateral aspects of the calcaneum are compressed (between thumb and forefinger) to elicit pain.
This is performed over the lower one-third of the posterior calcaneus. A positive test would reproduce the pain or symptoms.
Is the problem treatable by physio, chiro, massage?
Severs disease is a self-limiting condition and will generally resolve as the muscles adapt to the new length of bone. The problem may be recurrent during growth spurts, but the practitioner should inform the patient and/or the patient’s parents that this is not a dangerous disorder and that it will, generally, resolve completely as the patient matures (16-18 years old). Treatment depends on the severity of the child’s symptoms. As the condition is self-limiting, the patient’s activity level should be modified and limited only by pain.
Treatment techniques will include:
1. Managing inflammation with the rest, ice, compression, elevation (RICE) protocol
2. Reducing the load on the area by resting or modifying the aggravating activity/ies
3. Restoring ROM to the calf muscles via soft tissue release techniques, not end range stretching
4. Taping to unload the insertion point
5. Restoring normal biomechanics to the foot if this is identified as a contributing factor
6. Regaining normal muscle balance and strength through the muscles around the ankle
Severs disease is self-limiting and tends to coincide with periods of excessive growth, however 3 tips to minimise the risk, or the extent, of the injury occurring in the first place are:
1. Always ensure your child has correct, supportive footwear.
2. In the active child ensure they always engage in a well-rounded warm-up and, more importantly, cool down routine to maximise the length in the muscles.
3. Seek intervention early, if your child complains of heel pain, particularly if this coincides with a growth spurt, discuss the best management option with your healthcare professional early.
So that’s a brief overview of how Severs disease occurs. If you have any questions or comments please e-mail us at firstname.lastname@example.org and we will be happy to answer them for you.
If your child suffers with pain through the back of the heel, feel free to call us on (08) 9486 8653 and our therapists will be happy to chat with you about the best management plan.