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Practical Pearls For Treating Calcaneal Apophysitis
Sever’s disease, or calcaneal apophysitis, is a common cause of heel pain in the pediatric population. The patient will present with a chief concern of pain in the posterior aspect of the heel, either brought on by activity or occurring after the activity itself. While this is commonplace in pediatric sports medicine, in my private practice, I have recently noticed the condition present in a wide variety of children and foot types, regardless of engagement in sports, likely owing to lack of activity during the COVID-19 pandemic. Treatment options for this condition vary, most of the time depending on the clinician’s experience and personal success. In this article we aim to discuss the common presentation, appropriate examination, diagnosis, and treatment options for success.
Dr. James Warren Sever first described chronic heel pain, pediatric population as calcaneal apophysitis in 1912.1 The calcaneal apophysis is located at the posterior aspect of the calcaneus and adjacent to the insertion of the Achilles tendon. In Wiegerinck’s study in 2013, calcaneal apophysitis was found in 3.7 of 1000 patients between the ages of six and 17 years old.2 Thus, this is a pathology that a podiatric practitioner should expect to encounter.
Crucial History-Based Considerations For Diagnosis
It is always critical with a pediatric patient to begin with a thorough medical history. One way to accomplish this is with a thorough paperwork questionnaire filled out before the examination. However, I feel that speaking directly to the patient, as well as accompanying parents and other family members, to be the most effective method of obtaining a comprehensive history. In a study in the British Medical Journal, Hampton determined that initial diagnosis is possible 75 percent of the time based on history alone.3 Obtaining a quality medical history may save time, allowing you to direct your physical examination appropriately and rule out any other differential diagnosis involving posterior heel pain.
In my experience, it is prudent to set aside extra time for the pediatric patient regardless of pathology, as establishing a good rapport is critical in discerning a true history from the patient and their family members. Structured questions that begin in a tertiary fashion, allowing for easy “yes” and “no” answers, can lead to more focused questions that direct you to the appropriate location of the pain. The benefit of having parents, and even siblings, present during the examination is that it can allow the clinician to formulate an even more focused treatment plan based on other family members’ medical histories. Frequently a sibling, or even a parent, will relate a similar complaint in their history. They may remember a successful treatment method that relieved their problem, and you may choose a similar treatment plan for your patient.
In a pediatric patient it is also critical to obtain a good maternal, birthing, and developmental history. Any outlying issues discussed with the family member warrant further investigation regarding any prenatal insults, teratogenic issues, delivery complications, and delays in development. I find that it is common that these factors, especially developmental delay, could lead to predisposition to Sever’s disease, especially those involving the posterior leg.
The age and the activity level of the patient are also important. In the past, I’ve observed this condition associated with pubescent children in the middle of an increase in growth during times of increased activity. This increasing activity often occurred with fall sports after a summer of decreased activity. With the current environment, this return to activity may not be associated with the field of play, but rather increased activity to accomplish the activities of daily living that decreased during the pandemic. This is a unique observation for practitioners of our time. I notice that the simple task of being more active at school, such as walking from one class to another and up and down hallways, has proven a significant increase in activity level from the time of virtual learning and isolation in the house. While a child may not be a soccer player, lack of activity occurring from loss of physical fitness and immobility for prolonged periods may lead to a wider variety of patients presenting with Sever’s disease.
After taking a thorough history and developing a solid clinical suspicion for Sever’s disease, you can begin to direct your physical examination towards ruling out causes and determining whether it is inflammatory or biomechanical in etiology.
Understanding The Importance Of The Physical Examination
Appropriate physical examination includes evaluation of vascular supply to rule out any ischemic causes of the patient’s pain. While I find it is unique for a pediatric patient to present with early peripheral vascular disease, one does not want to miss any possibility of a decrease in blood flow to an area that could lead to osteochondritis or avascular necrosis. While uncommon in the age group, assessment for swelling and deep vein thrombosis need to be ruled out. During your history, acknowledgment of any hypercoagulable conditions would be essential to know.
A dermatological exam, either by palpation or direct visualization, can rule out or lend evidence towards possible infectious and traumatic causes. In my experience, neurological evaluation is essential to rule out any deficiencies that could lead to enhanced pressure to the posterior heel, including any spastic aspects involving the Achilles tendon and any peroneal muscular atrophy leading to a cavovarus foot type that would decrease shock absorption.
The musculoskeletal examination should be central to your evaluation of pediatric calcaneal apophysitis. The constant pull of the Achilles tendon on the secondary ossification center can cause inflammation and pain in the area of concern, especially in children who are physically active in sports, such as soccer, basketball, gymnastics, and track and field.5 The apophysis is two to five times weaker than the surrounding bone, muscle, and ligamentous structures.5 Therefore, as the child grows and before the epiphyseal plate ossifies, the apophysis is the weakest link in the posterior chain.
A force that might cause tendonitis or degeneration in an adult is more likely to cause apophysitis in a growing child.5 The most common age of patients presenting with Sever’s disease is eight to 14 years in boys and eight to 10 years in girls. The fusion of the apophysis is usually complete by 15 to 17 years of age.6 The hallmark of diagnosis is pain with a medial-lateral compression of the calcaneus in patients with an open growth plate and in the absence of obvious trauma.7
The Tanner Body Index stages a child’s growth based on the expectation of growth and aids in assessing the body’s ability to adapt to activity levels.8 Stages I and II are prepubescent individuals prior to growth spurts. Stages III (midpubescent) and IV (post-pubescent) represent a period of growth and maturation. Primarily in Stage III (Boys 12- 15; Girls 10-13), growth spurts will lead to joint tightness, all while undergoing bone growth that leads to the subchondral bone and physis being susceptible to microtrauma. This microtrauma can lead to inflammation of the posterior calcaneus, both acute and chronic in nature. It is important during the phase in the child’s life that there be an initiation of flexibility programs.8
A Closer Look At Biomechanical And Radiographic Examinations
Assessing the patient for equinus as a root cause of the presenting issue is paramount. Accordingly, evaluation of the source of the equinus is necessary to properly address the deforming force. Classically, one can utilize the Silfverskiold test, which allows you to isolate normal ankle dorsiflexion versus gastroc equinus or gastro-soleal equinus. In a standard test, there is normal dorsiflexion with the knee extended and flexed. Pure gastrocnemius equinus causes decreased dorsiflexion with the knee extended, but with the knee flexed, there is normal dorsiflexion. In pure gastrocnemius-soleus equinus, there is decreased ankle dorsiflexion with the knee both bent and extended.9,10 Also, when assessing for equinus, pay attention to the condition of the Achilles tendon itself. Palpating the tendon for continuity and as well for tendinopathy is wise.
Evaluation of foot position and type is necessary as both a pronated and a supinated foot can lead to increased force on the calcaneal apophysis. In the findings of a pronated foot or pediatric flatfoot, pronation at the subtalar joint can lead to dorsiflexion of the calcaneus, possibly giving mechanical advantage to the Achilles tendon, as seen in the above-referenced equinus. When this occurs and the child begins to increase activity, the force on the posterior calcaneus can increase, thus leading to the Sever’s condition.
In a cavus or supinated foot type, tightness in the posterior complex may be intrinsic. Also, a lack of pronation in the midfoot may lead to a decrease in shock absorption and dispersion throughout the foot. This shock absorption then focuses on the posterior calcaneus, potentially leading to the patient’s chief concern.
Without appreciating these factors, the root cause of the condition and the further perpetuation of the problem will continue. In my experience, the thought of this condition being “growing pains” and the world of “they’ll grow out of it” could lead to chronic injury, as well as a decrease in the child’s desire to be active, possibly leading to a downward progression in overall quality of life.
Differential diagnoses to consider include tendonitis, plantar fasciitis, peritendonitis of the Achilles, retrocalcaneal exostosis or bursitis, cysts and tumors, osteomyelitis, stress fractures, contusion, tarsal tunnel syndrome, or entrapment of the inferior calcaneal nerve. In extreme cases, Kumar and colleagues reported findings of osteomyelitis complicating Sever’s disease.11 Although there is a wide variety of confounding diagnoses, none will specifically exhibit pain with a medial-lateral calcaneal squeeze test without a broader spectrum of systems or a more obvious source of pain visible on plain film imaging.6
Next, it is critical to perform an appropriate radiographic evaluation, and to do so bilaterally. Assessing the growth plates with a unilateral film and no contralateral comparison may lead to misdiagnosis. Avulsion fracture in untreated Sever’s is a possibility.12 Rachel and team also reported abnormal radiographic findings in 5.1 percent of children with Sever’s leading to more aggressive treatment.13 They felt that without taking images, clinicians could miss lesions requiring more advanced treatment. Taking weight-bearing lateral images allows for evaluation of the calcaneus and a comparison of the two posterior growth plates for continuity and for advancement of closure. Evaluating for bone density, secondary ossification center, and fragmentation are also important.14 One should assess the widths of the growth plates should for possible increased separation or asymmetry, and the use of measuring options, now found on most computer radiography programs, can be helpful.
A dorsoplantar radiographic view can help determine foot type and position, especially at the talonavicular joint. I also utilize a calcaneal axial view with my pediatric patients, and due to their smaller stature, assessment of the hindfoot alignment is possible in this view as well. It is important to remember when treating the pediatric patient that you are treating not just the child, but the parents as well, and performing an X-ray does allow for additional peace of mind for the family.
In 2011, Vallejo and colleagues found a correlation between increased plantar pressures, gastrocnemius equinus, and patients with Sever’s disease.15 The case-control study evaluated 46 boys aged eight to 15 years who attended a soccer academy, 22 boys with unilateral Sever’s disease, and 24 healthy boys. Plantar pressure evaluation of all patients used pedobarography, and gastroc-soleus equinus was assessed with a goniometer.
In the Sever’s disease group, the symptomatic feet had a significantly higher peak pressure than the control group. The Sever’s group also had a significantly higher peak pressure in the symptomatic foot compared to the asymptomatic foot. Of note, all 22 children diagnosed with Sever’s disease had symptoms in the left heel, and 20 of these children had right-limb dominance, using the right foot to kick the ball while playing soccer. A statistically significant difference also existed between the two groups in prevalence of gastrocnemius equinus, with all 22 children in the Sever’s group having bilateral gastrocnemius equinus and 21 of 24 children in the control group having no equinus. This study seems to demonstrate the significance of gastroceniums equinus, increased plantar pressure, and unequal bilateral pressure distribution in the development of Sever’s disease.15
Treatment Options That You Should Know
After performing your history and physical examination, you must decide if the patient requires a period of immobilization to properly rest and decrease inflammation. One may evaluate this based on the patient’s tolerance to activity. Knowing when the pain occurs for the patient can direct your treatment. If the pain is constant, I find it is important to immobilize in a CAM boot for a short period of time, possibly one to two weeks, based on the patient’s response to treatment. Once controlling the inflammation, in my experience, one can stage return to activity with the help of an athletic trainer or physical therapist so as to not increase the level of activity too acutely, which could lead them back to pre-treatment pain status.
Based on the patient’s age, I find that the use of non-steroidal anti-inflammatory drugs, as well as ice to the area after activity can be beneficial for controlling inflammation and pain. This warrants discussion with the parents as to their preferences for this type of care when necessary.
In my observation, physical therapy is very helpful, including posterior release with suction techniques, such as Graston and intrinsic foot muscle training. I also feel that the use of an equinus brace directed for pediatrics can be extremely helpful, especially in short periods of time to enhance treatment tolerance. I do not recommend my patients wear the braces overnight, but rather for 30 to 60 minutes after activity, while resting at home, doing homework or are inside playing video games. In my observation, this make them more likely to use the device.
If your biomechanical evaluation notes pronation or supination deformities, it is essential to address them. In a supinated or cavus foot, the focus is towards shock absorption, which one may accomplish with heel padding like a Tuli’s® heel cup (Medi-Dyne®), or an increased rearfoot padded shoe like that found in a running shoe. If that treatment option fails, orthotic management to hold the foot in a rectus position and controlling the lateral position of the foot can be beneficial.
In a pronated foot type, a UCBL-style orthotic can help control pronation, as well as reduce the Achilles pull on the foot secondary to that mechanical issue. I have had success with pre-fabricated orthotics, which are very helpful since the child will likely rapidly grow out of custom orthotic devices. For this reason, a good system of pre-fabricated orthotics in your office can be helpful for patient retention, as well as continuing to provide support as for the child as they grow.16
In Conclusion
Micheli’s study in 1987 revealed a consistent two-month period of time for resolution of the Sever’s with the appropriate treatment.17 I feel in my practice that this is a realistic goal to share with the patient and family. The major issue I find with children is adherence to a treatment plan, so anything that can make it easier for the family will likely make the result more positive. In dealing preteens and teens, the patient has significant independence from a personal standpoint. A lot of the treatment execution depends on the children themselves, whereas in younger patients, the parents can be built-in compliance officers. Tailoring your approach and treatment for each patient and thoroughly explaining the “why” can lead to success. Treating children is very rewarding because, in my experience, they get better. They are healthy, growing, and constantly repairing themselves. Take light in this as you approach this special population.
Dr. Pagano is in private practice at Barking Dogs Foot and Ankle Care in Plymouth Meeting, PA. He is course director of Pediatric Foot and Ankle Orthopedics at Temple University School of Podiatric Medicine. He is the Vice President of the American College of Foot and Ankle Pediatrics and the on air expert for Spenco Medical on QVC. He specializes in Pediatrics, Sports Medicine and Surgery.
Dr. Suna Panah is an attending physician for the Einstein Medical Center Podiatric Residency Program. She is in private practice at Barking Dogs Foot and Ankle Care in Plymouth Meeting, PA.
Dr. James Allred is a second-year podiatric resdient at Einstein Medical Center in Philadelphia, PA.
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