Sever’s Disease

Calcaneal apophysitis, commonly known as Sever’s Disease is a common condition in young and physically active people that occurs due to inflammation of the growth plate in the heel bone (calcaneus) between the ages of 8-15 years old.

Causes

  • Children’s bones have a growth plate which is made up of cartilage near the end of bones. Over time as the skeleton matures this growth plate fuses.

  • Sever’s disease occurs due to the Achilles tendon pulling on its attachment to the calcaneus, resulting in inflammation of the growth plate.

  • Repetitive stress, increased exercise intensity, change in exercise activity and growth spurts are common causes of this inflammation.

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Signs & Symptoms

  • Pain localised to the heel and Achilles tendon

  • Pain aggravated by weight bearing activities such as walking, running, jumping

  • Recent increase in activity levels often precedes  injury

  • Usually occurs in periods of growth spurt (between 8-15 years old)

  • Pain in the heel when squeezing around Achilles tendon

Differential Diagnosis

  • Achilles tendinopathy

  • Retrocalcaneal bursitis

  • Calcaneal fracture

  • Plantar fasciitis

How to Manage

  • Education and advice regarding load management. This will be dependent on the child’s current function and pain levels. Often a period of offloading is required in the early stages if highly irritable.

  • Advice regarding return to activity and load management. Sever’s disease is a self-limiting injury and will improve when full skeletal maturity  is achieved, however it is important your child is able to stay active whilst managing there injury.

  • If applicable manual therapy to help improve ankle range of motion and decrease muscle tightness.

  • Prescription of a home exercise program targeted to impairments contributing to symptoms including lower limb and pelvic stability and control, strength and flexibility.

  • Following assessment of foot biomechanics, if appropriate advice regarding footwear and referral to Sports Podiatrist if necessary for orthotic review.

  • Management may also include referral to a sports doctor for review if any further medical intervention such as imaging, differential diagnosis and assistance with management plan.

References

  1. James A., Williams C., Haines T. (2013). Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review. Journal of foot and ankle research; 6(1): 16.

  2. Micheli L.J., Ireland M.L. (1987). Prevention and management of calcaneal apophysitis in children: an overuse syndrome. Journal of pediatric orthopedics; 7: 34-38.

  3. Wiegerinck J.I., Zwiers R., Siervelt I.N., van Weert H.C.P.M., van Dijk C.N., Struijs P.A.A. (2016). Treatment of calcaneal apophysitis: wait and see versus orthotic device versus physical therapy: a pragmatic therapeutic randomized control trial. Journal of pediatric orthopaedics; 36(2):152-157.

PROmotion Assessment and Outcomes Measures

  • Subjective examination including assessment of current and previous activity levels, past injury history, aggravating factors, footwear

  • Assessment of lower limb and pelvic stability and control through positions such as jumping, landing and running

  • Assessment of ankle range of motion, calf and foot strength, quadriceps, hamstring and gluteal strength and flexibility.

  • Palpation of heel and surrounding structures in the foot

  • Assessment of sporting footwear