Authored by Leland Jaffe DPM, Associate Dean and Professor, Scholl College of Podiatric Medicine; Published on February 2nd, 2024
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Sever’s Disease, also known as calcaneal apophysitis, is the most common cause of heel pain affecting children during periods of rapid growth, most commonly affecting children between the ages of 8-12. It occurs when the growth plate at the back of the heel, the calcaneal apophysis, becomes inflamed due to repetitive stress. This condition is prevalent in active children, particularly those involved in sports that involve running and jumping. In this blog post, we will explore what Sever’s Disease is, its causes, symptoms, and most importantly, the best treatment options to alleviate pain and promote healing.
Anatomy of the Heel Bone (Calcaneus)
An apophysis is a growth plate in the bone that doesn’t contribute to longitudinal bone growth. The calcaneal apophysis is located at the inferior and posterior aspects of the heel and is the growth plate of the heel bone into which the Achilles tendon attaches. The calcaneal apophysis shows increased metabolic activity during a growth spurt, which can place it at risk for overuse injury in young athletes. Sever’s disease is the most common cause of heel pain in children.
How To Diagnose the Cause of a Child’s Heel Pain
The diagnosis of Sever’s disease is often a clinical diagnosis based on the physical examination. The child’s history of foot pain in their heel that is related to activity and alleviated by rest often clues the parents or health care provider as to the diagnosis. Further, the child’s symptoms are not caused by an injury but have a gradual/subtle onset. The child may have worsened pain by wearing cleats that place direct pressure on the bottom and/or back of the heel.
Physical Exam Findings to Help Diagnose Sever’s Heel
During the physical exam, the health care provider directly palpates the apophysis at the back of the heel and performs a compression squeeze test, in which the palm is placed at the back of the heel and the heel is compressed. Pain that is elicited with the heel compression test is most often Sever’s heel but also could represent stress fractures, bone contusions, or an acute fracture of the calcaneal. This type of pain and + compression test very rarely represents plantar fasciitis or pain along the plantar fascia on the bottom of the heel. During the physical exam, the clinician will also often notice decreased ankle joint range of motion and flat feet or a high-arched foot.
X-rays and Advanced Imaging is Often Unnecessary
Making the diagnosis of Sever’s heel often does not require an x-ray or other type of advanced imaging. However, if the patient has an atypical physical examination or they are not responsive to treatment within 4-8 weeks, then an x-ray would be appropriate. The challenge with an X-ray is that discerning between normal and abnormal findings of the calcaneal apophysis can be challenging.
Some of the findings of Sever’s disease on radiographs include:
- Sawtooth appearance of the metaphysis
- Decreased density of the metaphysis (due to inflammation)
- Increased density of the apophysis
- Fragmentation of the apophysis
It should be noted that all of these findings on X-ray could be NORMAL!
Understanding Sever’s Disease:
Sever’s Disease typically manifests in children aged 8 to 14 years, especially during growth spurts. The growth plate, responsible for bone development, is more vulnerable to injury during this period. The constant pulling of the Achilles tendon on the heel’s growth plate can lead to inflammation, resulting in heel pain.
The most common symptoms of Sever’s Disease include:
- Heel pain, especially during or after sports activities.
- Swelling and tenderness at the back of the heel
- Difficulty walking or running
- Stiffness in the feet
- Discomfort when the sides of the heel are squeezed or when the back of the heel (growth center) is pressed
Treatment Options of Sever’s Disease in Children:
- Rest and Reducing Physical Activity:
- The most fundamental aspect of treating Sever’s Disease is giving the affected foot sufficient time to rest.
- Encourage the child to avoid high-impact sports, although this can be a challenge!
- Heel Cups – heel lifts (Tuli Heel Cups) – benefits of this treatment include SEE MY RECOMMENDATIONS FOR HEEL CUPS
- Shock Absorption: Heel cups provide effective shock absorption during activities like walking or running, reducing the impact on the heel and alleviating pain associated with Sever’s heel.
- Cushioning: The cups are designed to cushion and support the child’s heels, minimizing the stress on the growth plate and providing comfort to the affected area.
- Reduced Tension on Achilles Tendon: By providing support to the heel, heel cups can help alleviate tension on the Achilles tendon, a factor that can contribute to Sever’s heel.
- Encourages Natural Healing: Heel cups create an environment that promotes natural healing of the growth plate by minimizing further irritation and stress, allowing the child to engage in regular activities without exacerbating the condition.
- Improved Comfort: The cushioning effect of heel cups enhances overall comfort for the child, making it easier for them to move around and participate in daily activities without excessive pain.
- Prevention of Recurrence: Regular use of heel cups can contribute to preventing the recurrence of Sever’s heel by providing ongoing support and protection to the affected area.
- Ease of Use: Heel cups are typically easy to insert into shoes, making them a convenient and non-invasive option for managing Sever’s heel in children.
- Compatible with Footwear: Heel cups are designed to fit into most types of footwear, allowing children to use them with their existing shoes, whether for sports or everyday use.
- Non-Invasive Treatment Option: Heel cups offer a non-invasive alternative to more aggressive treatment options, providing relief without the need for surgery or extensive medical interventions.
- Ice Therapy:
- Applying an ice pack to the affected heel for 15-20 minutes several times a day can help reduce inflammation and alleviate pain.
- Ensure that a thin cloth or towel is used to protect the skin during ice application.
- Stretching Exercises:
- Regular stretching exercises, especially those targeting the calf muscles and Achilles tendon, can relieve tension on the growth plate. Tight calf muscles can contribute to this cause of heel pain in children.
- Toe stretches and wall stretches are beneficial in maintaining flexibility and
- Orthotic Support:
- Custom-made or over-the-counter shoe inserts (orthotics) can provide additional support and cushioning, reducing stress on the heel.
- SEE MY RECOMMENDATIONS FOR OVER-THE-COUNTER ORTHOTICS
- Ensure that the shoes provide proper arch support and shock absorption
- Footwear Selection:
- Encourage the use of supportive shoes with cushioned soles.
- Avoid shoes with inadequate arch support or excessive wear and tear.
- See the shoe-buying guide for children as described by the American Podiatric Medical Association
- Anti-Inflammatory Medications:
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help manage pain and reduce inflammation.
- However, it’s essential to consult a healthcare professional before administering any medication to children.
- Physical Therapy:
- A physical therapist can guide the child through targeted exercises to strengthen muscles and improve flexibility.
- They can also provide advice on proper biomechanics and body mechanics during physical activities.
- Gradual Return to Activity:
- Once symptoms have significantly improved, a gradual return to normal activities is recommended to prevent a recurrence of symptoms.
How to Manage Sever’s Disease – Conclusion:
Sever’s Disease can be a challenging experience for both children and parents. This condition is certainly the most common cause of heel pain in young people, however, with proper understanding and early intervention, it is a manageable, self-limiting condition that often resolves with conservative treatments. The key is to focus on a combination of rest, supportive measures, and professional guidance to ensure a full and pain-free recovery. If symptoms persist or worsen, it is crucial to seek advice from a (pediatric) podiatrist for further evaluation and tailored treatment recommendations.