Overview
Severs disease (calcaneal apophysitis) is a self-limiting condition seen in physically active children. Although there is controversy about the radiographic appearance, some reports propose the importance of fragmentation of the secondary nucleus in the diagnosis of Severs disease. We studied secondary nucleus of the calcaneus with ultrasonography. Twenty-one symptomatic heels of 14 children were examined. All these heels showed fragmentation of the secondary nucleus on both conventional radiograph and sonography. Ultrasonographic examination also showed 2 retrocalcaneal bursitis. Our initial data showed that sonography may be valuable in the diagnosis of Severs disease.
Causes
There are a number of possible causes for a child's heel pain. Because diagnosis can be challenging, a foot and ankle surgeon is best qualified to determine the underlying cause of the pain and develop an effective treatment plan. Sever's disease, also known as calcaneal apophysitis, is by far the most common cause of heel pain in children. Other causes of heel pain include tendo-achilles bursitis, other overuse injuries, and fractures.
Symptoms
The most prominent symptom of Sever's disease is heel pain which is usually aggravated by physical activity such as walking, running or jumping. The pain is localised to the posterior and plantar side of the heel over the calcaneal apophysis. Sometimes, the pain may be so severe that it may cause limping and interfere with physical performance in sports. External appearance of the heel is almost always normal, and signs of local disease such as edema, erythema (redness) are absent. The main diagnostic tool is pain on medial- lateral compression of the calcaneus in the area of growth plate, so called squeeze test. Foot radiographs are usually normal. Therefore the diagnosis of Sever's disease is primarily clinical.
Diagnosis
It is not difficult for a doctor to diagnose Sever's disease in a youngster or teenager. A personal history and a physical examination are usually all it takes to determine the cause of heel pain.
Non Surgical Treatment
Management by a health professional of Sever's disease is often wise. There are a few very rare problems that may be causing the pain, so a correct diagnosis is extremely important. Advice should be given on all of what is mentioned above, appropriate activity levels, the use of ice, always wearing shoes, heel raises and stretching, follow this advice. As a pronated foot is common in children with this problem, a discussion regarding the use of foot orthotics long term may be important. Strapping or tape is sometimes used during activity to limit the ankle joint range of motion. If the symptoms are bad enough and not responding to these measures, medication to help with anti-inflammatory may be needed. In some cases the lower limb may need to be put in a cast for 2-6 weeks to give it a good chance to heal. After the calcaneal apophysitis resolves, prevention with the use of stretching, good supportive shock absorbing shoe and heel raises are important to prevent it happening again.
Exercise
The following exercises are commonly prescribed to patients with Severs disease. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 1 - 3 times daily and only provided they do not cause or increase symptoms. Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms. Calf Stretch with Towel. Begin this stretch in long sitting with your leg to be stretched in front of you. Your knee and back should be straight and a towel or rigid band placed around your foot as demonstrated. Using your foot, ankle and the towel, bring your toes towards your head as far as you can go without pain and provided you feel no more than a mild to moderate stretch in the back of your calf, Achilles tendon or leg. Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free. Calf Stretch with Towel. Begin this exercise with a resistance band around your foot and your foot and ankle held up towards your head. Slowly move your foot and ankle down against the resistance band as far as possible and comfortable without pain, tightening your calf muscle. Very slowly return back to the starting position. Repeat 10 - 20 times provided the exercise is pain free. Once you can perform 20 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms. Bridging. Begin this exercise lying on your back in the position demonstrated. Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for 2 seconds then slowly lower your bottom back down. Repeat 10 times provided the exercise is pain free.
Severs disease (calcaneal apophysitis) is a self-limiting condition seen in physically active children. Although there is controversy about the radiographic appearance, some reports propose the importance of fragmentation of the secondary nucleus in the diagnosis of Severs disease. We studied secondary nucleus of the calcaneus with ultrasonography. Twenty-one symptomatic heels of 14 children were examined. All these heels showed fragmentation of the secondary nucleus on both conventional radiograph and sonography. Ultrasonographic examination also showed 2 retrocalcaneal bursitis. Our initial data showed that sonography may be valuable in the diagnosis of Severs disease.
Causes
There are a number of possible causes for a child's heel pain. Because diagnosis can be challenging, a foot and ankle surgeon is best qualified to determine the underlying cause of the pain and develop an effective treatment plan. Sever's disease, also known as calcaneal apophysitis, is by far the most common cause of heel pain in children. Other causes of heel pain include tendo-achilles bursitis, other overuse injuries, and fractures.
Symptoms
The most prominent symptom of Sever's disease is heel pain which is usually aggravated by physical activity such as walking, running or jumping. The pain is localised to the posterior and plantar side of the heel over the calcaneal apophysis. Sometimes, the pain may be so severe that it may cause limping and interfere with physical performance in sports. External appearance of the heel is almost always normal, and signs of local disease such as edema, erythema (redness) are absent. The main diagnostic tool is pain on medial- lateral compression of the calcaneus in the area of growth plate, so called squeeze test. Foot radiographs are usually normal. Therefore the diagnosis of Sever's disease is primarily clinical.
Diagnosis
It is not difficult for a doctor to diagnose Sever's disease in a youngster or teenager. A personal history and a physical examination are usually all it takes to determine the cause of heel pain.
Non Surgical Treatment
Management by a health professional of Sever's disease is often wise. There are a few very rare problems that may be causing the pain, so a correct diagnosis is extremely important. Advice should be given on all of what is mentioned above, appropriate activity levels, the use of ice, always wearing shoes, heel raises and stretching, follow this advice. As a pronated foot is common in children with this problem, a discussion regarding the use of foot orthotics long term may be important. Strapping or tape is sometimes used during activity to limit the ankle joint range of motion. If the symptoms are bad enough and not responding to these measures, medication to help with anti-inflammatory may be needed. In some cases the lower limb may need to be put in a cast for 2-6 weeks to give it a good chance to heal. After the calcaneal apophysitis resolves, prevention with the use of stretching, good supportive shock absorbing shoe and heel raises are important to prevent it happening again.
Exercise
The following exercises are commonly prescribed to patients with Severs disease. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 1 - 3 times daily and only provided they do not cause or increase symptoms. Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms. Calf Stretch with Towel. Begin this stretch in long sitting with your leg to be stretched in front of you. Your knee and back should be straight and a towel or rigid band placed around your foot as demonstrated. Using your foot, ankle and the towel, bring your toes towards your head as far as you can go without pain and provided you feel no more than a mild to moderate stretch in the back of your calf, Achilles tendon or leg. Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free. Calf Stretch with Towel. Begin this exercise with a resistance band around your foot and your foot and ankle held up towards your head. Slowly move your foot and ankle down against the resistance band as far as possible and comfortable without pain, tightening your calf muscle. Very slowly return back to the starting position. Repeat 10 - 20 times provided the exercise is pain free. Once you can perform 20 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms. Bridging. Begin this exercise lying on your back in the position demonstrated. Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for 2 seconds then slowly lower your bottom back down. Repeat 10 times provided the exercise is pain free.