Practical Pointers On Treating Sever’s Disease In Young Athletes

There are several causes of heel pain in the young athletic population with the most common being calcaneal apophysitis (also referred to as Sever’s disease). Sever first reported calcaneal apophysitis in 1912 as an inflammation of the apophysis, causing discomfort to the heel, mild swelling and difficulty walking in growing children.1

   The condition usually manifests between the ages of 8 and 14 with a higher incidence in boys than girls. In reality, however, calcaneal apophysitis is being diagnosed more frequently in girls due to their increase in participating in sports such as soccer, basketball and softball.

   There are many biomechanical factors that predispose a young athlete to calcaneal apophysitis. The majority of patients will present with an ankle equinus deformity, which ultimately exerts an increased pulling force to the Achilles insertion and non-ossified apophysis.2 Furthermore, patients may present with hyperpronation of the rearfoot. This allows more of a “teeter-totter” effect or lack of motion control on the frontal plane of the calcaneus. Treatment goals should focus on improving these biomechanical factors while the young athlete is undergoing skeletal maturation.

Pertinent Diagnostic Insights

The clinical presentation of calcaneal apophysitis will include posterior heel pain on medial and lateral compression. This is commonly referred to as the “squeeze test.” The young athlete may complain of pain to either one or both heels when walking or running, and at times during weightbearing after a period of rest. Patients may also describe a dull, achy pain to the heel with the absence of clinical swelling, redness or ecchymosis with dorsiflexion of the ankle. It is important to interview individuals (including parents, coaches and trainers) involved in the care of the young athlete in order to determine whether the patient has elicited any forms of compensation for the injury. These compensations can include toe-walking/running, early heel lift and limping.3

   Some authors have reported the condition to be an osteochondritis of the calcaneus while others have attributed the ailment to a “mechanical overuse syndrome.”4 Do not use plain film X-rays to definitively diagnose calcaneal apophysitis but rather to aid in ruling out any other causes of posterior heel pain such as calcaneal stress fracture, bone cyst, neoplasm or even a foreign body. It is beneficial to perform bilateral X-rays to compare any subtle differences between the pathologic and non-pathologic foot.

   A study conducted by Volpon and colleagues described the key radiographic finding for calcaneal apophysitis to be fragmentation of the apophysis.5 This “fragmentation” hypothesis was due to microtrauma and overuse of the posterior heel segment. Recent magnetic resonance imaging (MRI) studies have attempted to help understand the exact anatomic location of injury. Ogden and colleagues analyzed MRI findings to determine that the injury could be due to a metaphyseal stress fracture adjacent to the apophysis.6 One should diagnose calcaneal apophysitis by clinical findings. An MRI is rarely required.

Keys To Addressing Pain And Correcting Biomechanics

It is imperative to reassure the caretakers of the young athlete that calcaneal apophysitis is a self-limiting disease. Avoid the term “disease” when discussing the condition with parents and use terms such as “growth plate swelling” to ease the anxiety of the diagnosis. As is the case with most sports-related injuries, rest and reduction of pain are the keys to the patient’s return to sports.

   Complete immobilization using a below-knee cast can be harsh to the psyche of the young athlete and harsh physically on extremity musculature. A superior approach is to allow protective weightbearing with a controlled ankle motion (CAM) walker and crutches (if necessary) during the acute phase for two to three weeks.7 One can prescribe analgesics such as non-steroidal anti-inflammatory medications (NSAIDs) at this time as necessary along with daily icing to the affected heel. This initial period of treatment can be referred to as “rest and recovery.”

   After two to three weeks, the young athlete should show clinical signs of either diminished pain or elimination of pain upon the “squeeze test” of the heel. At this point, treatment should focus on the following: increasing the strength of the young athlete and improving the biomechanical factors that contributed to the calcaneal apophysitis.

   First, to avoid disuse atrophy, allow the patient to perform low-impact exercises such as the use of a stationary bike (at low resistance) and swimming. You can allow walking at a treadmill at low speed but only if you first fit the patient for a heel lift for a shoe with a rigid heel counter and adequate shock absorption. Therefore, it is good clinical practice to evaluate the young athlete’s shoe gear at this point of treatment.

   Secondly, institute a daily stretching regimen to address the ankle equinus. It is important to demonstrate the stretching instructions to the parents and/or coaches. Patients can perform stretching using a towel, belt or elastic stretching band two to three times daily. One can also dispense a dorsiflexory night splint for the patient to wear one hour daily for each limb if adherence to the stretching regimen is a concern.

   After two to three weeks of following the “stretching and strengthening” protocol, the young athlete should exhibit signs of complete relief. Fabricate orthotics with deep heel cups and a vertical rearfoot posting for added motion control of the calcaneus. Furthermore, one should utilize heel lifts, which can be built into the orthotic device, to decrease the strain on the Achilles tendon. The orthotic device may need to be customized for particular performance shoes such as cleats. Instruct the patient and parents to bring the shoes into the office for evaluation prior to giving medical clearance for the young athlete to return to sports.

   If the patient is still symptomatic at this point of treatment, physical therapy may be necessary with a sports therapist for an additional three weeks. At this point, there is clinical reasoning to order an MRI to evaluate other plausible causes of heel pain.

In Conclusion

Calcaneal apophysitis can be a painful and debilitating condition for the young athlete. From the clinical standpoint, diagnosis should primarily be based on clinical findings and only reinforced with radiographic measures. The treatment follows a pattern that is common practice in sports medicine. There is a period of “rest and recovery” followed by a period of “stretching and strengthening.” Keep in mind that most young athletes are able to return to their respective sports after a period of four to eight weeks.

   Clinicians have the role of educating the coaches and parents that calcaneal apophysitis is an overuse injury that can be prevented. More children are participating in school sports and at a competitive level. Accordingly, parents should proceed with caution when their rapidly growing child is involved in multiple sports throughout the course of a year.

   Dr. Basra is an Associate of the American College of Foot and Ankle Surgeons. He is in private practice at Active Foot and Ankle Care in Fair Lawn, N.J., and is a consulting team physician for Montclair State University. Dr. Basra is also a clinical instructor at New York Methodist Hospital in Brooklyn, N.Y.

   Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.

References
1. Sever JW. Apophysitis of the os calcis. NY State J Med. 1912; 95:1025–9.
2. Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987;7(1):34–8.
3. Liberson A, Lieberson S, Mendes DG, Sharjrawi I, Ben Haim Y, Boss JH. Remodeling of the calcaneal apophysis in the growing child. J Pediatr Orthop B. 1995; 4(1):74-79.
4. Volpe R. Keys to diagnosing and treating calcaneal apophysitis. Podiatry Today. 2009; 22(11):60-66.
5. Volpon JB, de Carvalho Filho G. Calcaneal apophysitis: a quantitative radiographic evaluation of the secondary ossification center. Arch Orthop Trauma Surg. 2002; 122(6):338–41.
6. Ogden JA, Ganey T, Hill JD, et al. Sever’s injury: a stress fracture of the immature calcaneal metaphysic. J Pediatr Orthop. 2004; 24(5):488–92.
7. Chiodo W, Cooke, K. Pediatric heel pain. Clin Pod Med Surg. 2010; 27(3):355-366.