Treating Calcaneal Apophysitis In Young Athletes This Fall

With the fall sports season well underway, an increasing number of young athletes are presenting to my office with heel pain. Calcaneal apophysitis, also known as Sever’s disease, is a traction apophysitis resulting from repetitive microtrauma created by the pull of the Achilles tendon.^1,2 The onset of symptoms often occurs during the beginning of a new sport season or gym class with an adolescent patient complaining of pain in one or both heels. Fortunately, this is a self-limiting condition and symptoms resolve after fusion of the apophysis.

The exact pathogenesis of calcaneal apophysitis is unclear. The calcaneal apophysis appears as an independent ossification center between 7 and 9 years of age with fusion occurring between 15 and 17 years of age.¹ Researchers have theorized that microtrauma caused by the pull of the Achilles tendon allows for microscopic movement of the apophysis relative to the body of the calcaneus.³ The vertical orientation of the apophysis, coupled with the pull of the gastroc-soleus complex, creates strong shear stresses, resulting in the apophysitis.¹

Calcaneal apophysitis is most common in boys between the ages of 10 and 12, and in girls between 8 and 10 years of age.¹ High levels of athletic activity, increased body mass index and increased height in comparison to the general population are risk factors associated with the development of calcaneal apophysitis in children.¹ Other factors contributing to the development of calcaneal apophysitis include shoe gear, participation in high-impact sports and running on hard surfaces.¹

The diagnosis of calcaneal apophysitis is often clinical. A young patient will present with complaints of pain in one or both heels in the area of the Achilles tendon insertion. Pain to palpation over the posterior aspect of the heel in the area of the Achilles tendon insertion will be present. Mild edema and erythema may overlie the painful area. Patients may demonstrate antalgic gait with relief of pain from walking on the toes.¹ Radiographic evaluation often demonstrates normal calcaneal apophysitis. In some cases, increased sclerosis and fragmentation of the calcaneal apophysis may be apparent.³

Treatment of calcaneal apophysitis is patient dependent and one should gear treatment toward the severity of symptoms. All patients should begin with modification of activity, such as decreased running and jumping, in combination with aggressive stretching of the gastroc-soleus complex.³ I often recommend a physical therapy consult in an attempt to have the patient back to the sport as quickly as possible. Patients can wear a ¼ inch Poron heel lift in athletic shoes to decrease traction of the Achilles tendon on the apophysis.

In rare cases of severe or recalcitrant pain, the patient may require complete immobilization and rest in a controlled ankle motion (CAM) boot to allow symptoms to resolve. Most patients are able to return to their sport unrestricted and pain-free within four to six weeks.³

References

1. Hendrix CL. Calcaneal apophysitis (Sever disease). Clin Podiatr Med Surg. 2005; 22(1):55-62.
2. Scharfbillig RW, Jones S, Scutter SD. Sever’s disease: what does the literature really tell us? J Am Podiatr Med Assoc. 2008; 98(3):212-223.
3. Cassas KJ, Cassettari-Wayhs A. Childhood and adolescent sports-related overuse injuries. Am Fam Physician. 2006; 73(6):1014-1022.