What is Sever Disease (Calcaneal Apophysitis)?
Sever disease, also known as calcaneal apophysitis, is a common reason for heel pain in young athletes or children between the ages of 8 to 15 who are still growing. This condition happens when there’s a recurring minor injury to a part of the heel bone where growth occurs, this is often due to stretching of the Achilles tendon. The problem is often linked to a condition where a muscle in the calf is shorter than usual, which happens because bones and muscles don’t always grow at the same rate. Sever disease is common in young people who play sports involving running and jumping. Pain can happen suddenly when a child starts participating in sports more frequently, particularly during a growth spurt. However, the pain usually goes away when they rest or stop the activity. This disease can also occur in less active teenagers who wear flat shoes.
People with Sever disease often report that their pain goes away during rest periods or when the part of the heel where growth occurs fully matures. A healthcare professional can often detect the disease by applying pressure to the area where the Achilles tendon attaches to the heel. A positive diagnosis of Sever disease does not require imaging studies like an MRI or an X-ray, but these can be helpful in ruling out bone fractures, infections, or tumors.
Sever disease generally resolves on its own, and treating it often involves changing or reducing activities that cause pain. Managing symptoms may include using anti-inflammatory medicines, applying ice, using heel cups or heel lifts, and in very painful cases, restricting movement. A rehabilitative program that places emphasis on stretching and strengthening the heel cord should be part of the care plan to help relieve the symptoms and address the underlying factors that may make a person more likely to develop the condition.
What Causes Sever Disease (Calcaneal Apophysitis)?
Sever disease is an injury that often comes from doing the same action too much and putting repeated strain on a particular part of the body. This happens when the strong Achilles tendon, which is located at the back of your ankle, places pressure on a softer part of your heel bone (known as the calcaneal apophysis). The issue occurs when this bone grows faster than the muscles surrounding it, and this results in irritation.
As children experience rapid growth and increased physical activity, the force from the Achilles tendon becomes more intense. It’s also important to note that factors contributing to your risk of getting Sever disease include being overweight, intense sports activities, limited movement of the ankle, poorly padded or worn out sports shoes, running on hard surfaces and certain foot shapes or conditions. The sports where you see this condition the most involve a lot repeated running and jumping, like basketball, soccer, track, cross-country, and gymnastics.
Usually, this condition isn’t associated with a sudden injury or trauma. However, in rare instances, a severe injury may cause a complete tear or ‘avulsion fracture’ of this part of the heel bone.
Risk Factors and Frequency for Sever Disease (Calcaneal Apophysitis)
Sever disease is a condition that typically shows up during the period of rapid growth in children and teenagers, usually between 8 to 15 years of age. It is one of the main reasons for heel pain in this age group and is linked to 2% to 16% of all problems related to muscles and bones in children. Interestingly, the symptoms of Sever disease commonly show up in only one foot, but in about 60% of cases, both feet hurt. Boys are more likely than girls to get this condition, with boys being 2 to 3 times more likely to develop it. The usual age it starts is around 12 for boys and 11 for girls.
- Sever disease is common during the rapid growth of active kids and teenagers, usually from 8 to 15 years old.
- It is one of the main causes of heel pain in teenagers, making up 2% to 16% of all muscle and bone issues in children.
- Although symptoms usually appear in one foot, up to 60% of patients feel pain in both feet.
- Boys have a 2 to 3 times greater chance of developing this disease compared to girls.
- The average age when the disease starts developing is about 12 for boys and 11 for girls.
Signs and Symptoms of Sever Disease (Calcaneal Apophysitis)
Sever’s disease is a condition that often affects active kids or teens between the ages of 8 to 15. It causes heel pain that gets worse during and after physical activity, especially when running or jumping. The person suffering from this disease may not remember a specific incident when the pain started, but it’s usually connected to a recent growth spurt, a new sport or fitness routine, or at the start of a sports season.
Regarding symptoms, the pain typically reduces with rest and is often not present in the morning. Over time, the pain could get worse and possibly limit the person’s activity. Mild swelling and tenderness might be noticed near the Achilles tendon at the back of the heel.
During a physical examination, medical professionals check for telltale signs such as:
- Pain when the ankle is flexed upwards
- Pain when pressure is applied to the back of the heel from both sides
- Kids standing on tiptoes to avoid putting pressure on the affected heel (known as the Sever sign)
- Flexibility limitations in the heel cord or poor strength in ankle dorsiflexion
- Limping or toe walking to avoid heel pressure
Expect no redness or bruising to be seen in the area of pain.
Testing for Sever Disease (Calcaneal Apophysitis)
Sever’s disease is normally diagnosed based on the patient’s symptoms and a physical check-up. The only time more testing might be needed is when the symptoms are unusual, very bad, or don’t get better after 4 to 8 weeks of normal treatment. At this stage, your doctor may suggest some additional tests to make sure there’s no infection, cancer, or hidden fracture.
Normal X-rays often show hardening and broadening of the growth plate, but these changes can also be seen in normal people. When the doctor requests an X-ray, they might recommend doing both sides to identify any bone abnormalities. An MRI (Magnetic Resonance Imaging scan) is actually better at telling the difference between Sever’s disease, tumors, and infection.
The results of your blood tests will normally be within the average range. If you have raised levels of inflammatory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), it might indicate a bone infection. In less than half of the cases of heel bone infection, there is a raised white blood cell count. However, CRP and ESR levels are raised in up to 77% and 95% of cases, respectively.
Treatment Options for Sever Disease (Calcaneal Apophysitis)
Sever disease is a condition in young people that typically gets better on its own as the person grows and matures. The main goal of treatment is to relieve pain, and there’s no need for surgery in Sever disease.
Activities that cause pain, like running and jumping, should be limited. In some instances, it may be necessary to stop participating in sports temporarily until symptoms improve.
Applying ice on the painful spot for 20 minutes each day can be beneficial. Ice narrows the blood vessels and limits the flow of inflammation-causing cells to the area. Combining ice with periods of rest can help reduce inflammation.
Using foot supports – heel lifts, heel cups, heel pads – can lessen the stretch on the growth plate in the heel and relieve pain. These can be especially useful in sports shoes with cleats which can worsen symptoms by focusing impact forces on the heel.
In cases that don’t improve within 4-8 weeks, it may be necessary to keep the foot stable without any movement. This can be done with a cast or by using a boot that prevents movement in the foot, also known as a CAM boot.
In the early stages, oral non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can be used to decrease inflammation. However, it’s not advised to let the patient use these medications before physical activity to allow them to play longer with less or no pain. Topical ketoprofen can be effective, but it’s not recommended for children under 12.
Braces can be useful for athletes who perform barefoot activities and can’t wear foot supports, like gymnasts and dancers. These athletes can experience significant improvement in their pain scores and performance when using certain types of heel cup and braces.
There is some evidence that kinesiology tape (stretchy therapeutic tape applied to the skin) can provide immediate pain relief. This tape method can help regulate blood flow, flush out inflammation-causing substances, and lessen tension and stress in the affected area.
Exercises and stretches that target the calf muscles can help ease the discomfort caused by the tendon connected to the heel bone (the Achilles tendon) pulling on the heel. Strengthening neighboring muscles can also lighten the load on the Achilles tendon.
Physical therapy, which includes stretches, strength exercises, and sometimes ultrasound or electrical stimulation, can be beneficial. Professional guidance from a physical therapist may be necessary if a home stretch and exercise program doesn’t lead to improvement.
A study that compared rest, the use of foot supports, and physical therapy for treatment of Sever disease found all three methods significantly decreased pain, with no method proving more effective than the others.
The main treatment for Sever disease often includes rest, ice, calf stretches and strength exercises, foot supports, and NSAIDs. In severe cases, or those that don’t respond to physical therapy and other methods, immobilization with a cast or CAM boot may be necessary. Braces can help people participating in barefoot activities.
The symptoms of Sever disease usually get better within a few weeks to months. Although the condition might come back, especially during periods of increased activity, it won’t continue after the growth plate in the heel (apophysis) closes. Treatment doesn’t include injection therapy or surgery.
What else can Sever Disease (Calcaneal Apophysitis) be?
There are several health conditions that might look like Sever disease, so doctors need to do a complete medical review and thorough physical checkup to tell the difference. Scans may be necessary if the condition seems unusual, particularly serious, or it doesn’t improve over time. Although in most cases, conditions can be identified through MRI scans, breaks in the heel bone and a condition known as ‘tarsal coalitions’ can only be detected by taking regular X-rays.
There are also various health issues that have similar signs to Sever disease. Therefore, medical professionals need to carefully check for the following, to make sure they make the correct diagnosis:
- A tear in the Achilles tendon
- Inflammation of the Achilles tendon
- Inflammation at the back of the heel (retrocalcaneal bursitis)
- Heel bone fractures
- Cysts in the heel bone
- Bone infection (osteomyelitis)
- A condition where some bones in the foot fuse together (tarsal coalition)
- Inflammation of the tissue on the bottom of the foot (plantar fasciitis)
- Bruising of the heel
- Soreness at the back of the ankle (Posterior ankle impingement)
- Bone tumors.
What to expect with Sever Disease (Calcaneal Apophysitis)
Sever disease is a condition that often comes back, but it’s important to know that the symptoms usually go away once the growth plate in the heel (known as the apophysis) fully matures. This means that once a person has finished growing, they shouldn’t expect to see any more symptoms related to this disease.
Possible Complications When Diagnosed with Sever Disease (Calcaneal Apophysitis)
People with Sever’s disease can also suffer from inflammation of the Achilles tendon and inflammation of the tissue that runs along the bottom of your foot. The only known complication of Sever’s disease is osteomyelitis, a severe infection of the bone, which has been reported in a few documented cases. If osteomyelitis is suspected, an MRI scan should be carried out immediately for a detailed examination. The normal treatment involves taking antibiotics for six weeks, which can clear the infection and improve symptoms.
Common Conditions Associated:
- Inflammation of the Achilles tendon
- Inflammation of the tissue at the bottom of the foot
Common Complications:
- Osteomyelitis (severe bone infection)
Recommended Actions:
- Get an immediate MRI scan if osteomyelitis is suspected
- Undertake a six-week course of antibiotics to clear the infection
Recovery from Sever Disease (Calcaneal Apophysitis)
Rehabilitation care typically involves using ice and following particular routines for stretching and building strength. These routines can be done by yourself at home or under the guidance of a physical therapist. The therapist may also use specialized treatments, like ultrasound technology or electrical stimulation.
The specific exercises recommended often include stretching the gastrocnemius muscle, which is a major muscle in the calf, and doing heel raises to strengthen your muscles in an eccentric way. Eccentric strengthening means you’re strengthening the muscle while it’s being elongated.
Preventing Sever Disease (Calcaneal Apophysitis)
Sever disease, also known as calcaneal apophysitis, is a condition that causes inflammation, or swelling, at the growth plate in the heel. This growth plate is the area where the calf muscles at the back of the leg and the Achilles tendon attach to the foot. In children, growth plates are areas where new bone is being produced. This active area matures into solid bone once the child reaches full physical growth.
When a child experiences a growth spurt, their bone can grow quicker than the associated muscles and tendons, creating tension from the Achilles tendon on the growth plate. Activities such as starting a new sport, a sudden increase in physical activity, obesity, and structural foot problems like flat feet can cause irritation in the heel area. This irritation can lead to Sever disease. Common signs of this condition include pain at the back of the heel after physical activity, limping, walking on the toes, and difficulty engaging in activities like running and jumping.
To diagnose Sever disease, medical professionals primarily look at the symptoms, this is called a clinical diagnosis. They don’t necessarily need x-rays or specialized tests to confirm the condition. However, if the symptoms are severe, unusual, or don’t improve after 4 to 8 weeks, further tests like x-rays, MRIs, or lab tests may be done to rule out more serious issues.
The good news is that Sever disease generally improves on its own over time and the main aim of treatment is to help with discomfort. Ice, rest, and anti-inflammatory medications can manage pain initially. Heel cups or pads may also offer relief. Custom-made shoe inserts called orthotics can address foot structure issues. For severe cases, devices like braces might be used, and some patients may even need to wear a cast. When the pain has lessened, exercises that stretch the calf muscles and strengthen the leg muscles become important. While Sever disease can come back, especially after increased physical activity, it completely goes away when the growth plate matures into solid bone. To help prevent recurring discomfort, stretching and strengthening exercises are continued, and shoes with good heel cushioning should be worn.
