What is Sever’s Disease?
Sever’s disease, also known as calcaneal apophysitis, is the most common cause of heal pain in a young athlete. The underlying problem is inflammation in the growth plate in the heel (this type of growth plate is called an apophysis). Although it is not a true “disease” it can still cause a lot of problems for a young athlete trying to better themselves in their sport and can sideline even the greatest “greek warrior”; after all the Achilles tendon attaches to the calcaneal apophysis.
What causes Sever’s disease?
Sever’s disease is often due to the perfect storm, including a combination of micro trauma from overuse, recent growth, and other biomechanical imbalances such as flat feet (or foot pronation) and muscle weakness in the foot. As the Achilles tendon pulls on the heel of the foot (calcaneus bone) the growth plate on the back of the heel can become irritated over time. This irritation can make the heel very painful and hard to walk or stand on. The most common contributor is overuse from sports that require a lot of running, particularly soccer and baseball where the shoes are less forgiving, but other causes do exist.
Other causes include:
- Having a tight achilles tendon and/or calf muscle
- Recent and rapid bone growth of the shin bone (tibia), which causes increased stretch on the calf and Achilles tendon
- Poor footwear with little to no support, such as soccer cleats
- Poor muscle control in the feet, contributing to flat or pronated feet
Who can this affect?
Sever’s disease can affect children most commonly from 8-12 years of age, and sometimes slightly older. At around age 12 the incidence of Sever’s disease drops precipitously because the heel bone (calcaneus) growth plate begins to close. It can affect young athletes in any sport, especially sports with lots of running and jumping.
Common sports Include:
- Soccer
- Track
- Basketball
- Even soldiers involved in the Siege of Troy
What are the symptoms?
The most common symptom of Sever’s Disease is Heel Pain. The pain can be on the back or bottom of the heel. Other symptoms include limping, heel pain worse with activity, heel pain with pulling the foot up, pain when heel is squeezed from the sides, and excessive walking on toes.
How is Sever’s Disease diagnosed?
Sever’s disease is usually diagnosed with a good history and physical exam. Often x-rays of the foot are ordered to confirm no other condition that could explain the pain, such as a bone cyst, avulsion fracture, or bone fracture.
How is Sever’s Disease treated?
First line treatment is very conservative and includes:
Relative rest— decreasing activity or taking time off from a sport can give the body time to heal. Based on the patient’s pain level, we can dial back the activity level and/or provide 1-2 weeks away from pain inflicting activities.
Medications— over the counter NSAIDs, like Ibuprofen can help with pain and inflammation; or analgesics like Tylenol can help with pain.
Icing— similar to the effects of ibuprofen, ice can help decrease pain and inflammation, particularly after physical activities that worsen pain.
Foot support— making sure to have proper footwear and heel support can help prevent Sever’s and aid in treatment. Options include gel inserts, custom orthotics, or heel lift, or heel cup.
Immobilization— in active kids who can’t be slowed down, or won’t be compliant with treatment in a walking boot, another option is to wear a cast sometimes with the use of crutches to immobilize the foot, promoting much quicker pain relief.
Physical Therapy— A combination of stretching and strengthening can help treat pain and prevent recurrence.
A great exercise to strengthen and stretch the Achilles tendon and calf includes:
1. Eccentric Heel raises: standing on the edge of small ledge, you can lift up your heel and slowly let your foot sink sink down.
Eccentric Heel Raises
Exercises that promote intrinsic foot strength can also be helpful, such as:
2.Towel scrunches: Put a towel on the floor. While seated, pull the length of the towel underneath your foot using your toes, making 3-5 passes per day.
Towel Scrunches
For refractory cases of Sever’s Disease, Prolotherapy can be an option. Prolotherapy can be performed with hyperosmolar dextrose solution.
Hyperosmolar Dextrose injections can be safely used to stimulate the body’s own intrinsic repair mechanisms to recruit the natural inflammatory process, promoting healing as well as tissue repair and remodeling. It is thought to synthesize new collagen tissue to strengthen the area, getting you or your child back to fighting the Trojans! Dr. Minor has been performing these injections for recalcitrant Sever’s and Osgood-Schlatter’s diseases for several years.
When can I return to my sport?
The amount of treatment needed and the time needed for healing can differ greatly between patients with Sever’s disease. In general, the longer the child has had symptoms before treatment is started, the longer it takes to heal. For the most part, pain guides return to play. If the child has no or minimal pain associated with activities such as jogging, sprinting, and hopping on affected foot it becomes more apparent that he or she is ready to return.
Does Sever’s disease ever come back?
You should be aware that Sever’s disease can be like riding a bad roller coaster. It can appear to be fully resolved, then without much warning return with a vengeance. Typically there is no warning, but in retrospect you may realize a bad combination of recent growth as well as playing many hours of sports per week, or playing for multiple teams or multiple sports with excessive running and jumping. During a bad flare or recurrence, we generally recommend treating these conservatively to start, and be more aggressive if not making progress later.
By Thomas Sellers & Jon Minor, MD
Sources:
“Calcaneal Apophysitis (Sever’s Disease).” ACFAS, www.acfas.org/Content.aspx?id=1483.
University of Wisconsin Hospitals and Clinics Authority. “Calcaneal Apophysitis (Sever’s Disease).” UW Health, www.uwhealth.org/sports-medicine/clinic/calcaneal-apophysitis-severs-disease/13067.
Hyperosmolar Dextrose Injection for Recalcitrant Osgood- Schlatter Disease by Gastón Andrés Topol, MD, Leandro Ariel Podesta, MD, Kenneth Dean Reeves, MD, Marcelo Francisco Raya, PT, Bradley Dean Fullerton, MD,and Hung-wen Yeh, PhD
Sever Disease (Calcaneal Apophysitis) pamphlet Ann and Robert H Lurie Childrens Hospital of Chicago
Images:
“Towel Scrunch – Foot Activation Exercise.” PreHab Exercises, www.prehabexercises.com/ankle-activation/activation-exercise-towel-scrunch-foot/
“Aspects of treatment for posterior heel pain in young athletes” Thomas Legard Open Access journal of Sports medicine
“What’s your company’s Achilles Heel?” LA Ads, www.laadsmarketing.com/whats-your-companys-achilles-heel/.
“Sever’s Disease – Calcaneal Apophysitis – Huntington, NY Foot Doctor.” Kalmar Family Podiatry of Huntington, NY – Podiatrist in Huntington, NY – Foot Doctor Huntington, NY, www.kalmarpodiatrygroup.com/severs-disease—calcaneal-apophysitis.html.
