Sever’s Disease – assessment and treatment of calcaneal apophysitis
Sever’s disease refers to the condition calcaneal apophysitis, an inflammation of the growth plate in the heel. It presents as a moderate to severe pain in the heel and occurs in children and adolescents, particularly in those who are more physically active. It is caused by repetitive stress to the heel. While it usually resolves once the bone has finished growing, it can be distressful and debilitating.
In this article, we will look at how the condition arises, its assessment and treatment. We will summarise the wide range of treatments that have been used, but with focus on recently published research (2016) that compares the outcome of various orthotic treatments with a “wait and see” approach.
Children usually present with heel pain in one or both heels that is aggravated by physical activities such as playing sport, running or walking. The pain occurs at the back of the plantar side of the heel over the calcaneal apophysis and can be severe, causing the patient to limp and limiting their physical and sporting activity. In appearance, the heel usually appears normal.
Usually Sever’s disease affects children aged 8 to 14 years and is more common (64%) in boys, most of whom (61%) are affected in both heels. During this growth stage growth plates have yet to become fused and ossified with additional weakening resulting from fragility of the calcified cartilage. This makes them susceptible to overuse injury particularly when combined with excessive pronation.
Physical examination usually reveals tenderness when carrying out the “squeeze test” (medial and lateral heel compression). This will identify local pain and this, combined with the child’s medical history, is usually adequate to diagnose the condition. Additional assessments include reduced ankle dorsiflexion, excessive pronation or supination, and tight calf muscles. Usually there are no signs of oedema, erythema or skin abnormalities.
There are few heel conditions that replicate the symptoms of Sever’s disease, and although X-ray imaging can confirm its diagnosis, current thinking (Kose 2010) suggests that while imaging can rule out other conditions such as bone cyst, fracture, neoplasm, tarsal coalition or osteomyelitis, in the absence of history or physical findings of these conditions “obtaining radiographs as an initial step in the evaluation does not seem to be justified”. However, for children with persistent heel pain despite adequate treatment or when the pain increases with rest, there is swelling and other physical changes a radiograph is indicated (Russel et.al., 2009).
A wide range of treatments are used for Sever’s disease. These include:
- Full immobilisation
- Hamstring and calf muscles stretching regimens
- Rest, Ice, Compression, Elevation
- Daily icing
- Heating therapy
- Physical therapy
- Deep tissue massage
- Heel lifts
- Foot orthotics
There have been few randomised studies carried out on these alternative treatments and the most effective treatment calcaneal apophysitis is currently unknown (Wiegerinck, 2016). However recently several randomised trials have been carried out on the evaluation of alternative treatment modalities with groups of children aged 8–14 years with clinically diagnosed calcaneal apophysitis.
Shields (2016) compared the outcomes of three approaches.
- Wait and see
- Wearing a heel raise
- Eccentric exercise
Shields (2016) used a randomised trial on children aged 8 to 15 years diagnosed with calcaneal apophysitis. The children self-reported pain greater than 30 mm on the Faces Pain Scale-Revised and had a positive squeeze test. X-rays were normal and no other leg injuries had occurred in the previous 12 months. Of the 96 subjects:
- 32 patients were allocated to the wait and see group. These stopped pain inducing activities and recommenced them after the pain subsided.
- 33 to the heel raise group who wore prefabricated inlays in both shoes daily and had no restrictions placed on their activities.
- 33 to the eccentric exercise group who carried out physiotherapist supervised eccentric calf strengthening exercises and daily exercises at home, again with no restrictions on their activities.
Primary outcomes were assessed by change in the Faces Pain Scale-Revised at 6 weeks and 3 months and secondary outcomes by Oxford Ankle and Foot Questionnaire & child and parent report of foot-specific disability and a satisfaction score. The outcomes were:
- Pain reduction was similar for all three groups.
- At 6 weeks, the child-reported foot-specific disability improved more in the heel raise group than the wait-and-see group
- The parent-reported foot-specific disability improved more in the eccentric exercise group than the wait-and-see group
- There were no differences between the groups for child and parent reported foot specific disability at 3 months.
- Patient satisfaction was higher in the heel raise group compared with the other two groups at 6 weeks only.
As wait and see, wearing a heel raise and eccentric exercise each resulted in a significant reduction in pain and foot-specific disability, Shields (2016) concluded that patients and parents should be consulted about their preferred treatment option.
In a similar study (Wiegerinck et. al., 2016) a randomised trial was used to assess treatment duration of 10 weeks using the same modalities on total of 101 subjects. After 6 weeks, heel raise subjects reported greater satisfaction than the other groups, though at follow-up no differences were found between the different modalities. Again, the recommendation was that “physicians should deliberate with patients and parents regarding the preferred treatment”.
James et. al. (2016) compared two different types of in-shoe orthoses: a heel raise or prefabricated orthoses on a group of 124 children. After 2 months, heel raises performed better than prefabricated orthoses, though at 12 months there was no difference in the effect of different treatment choices, again suggesting that patient preference should be an important factor in treatment selection.
Sever’s disease is for most patients self-recovering and will resolve once bone growth is completed and with rest. Generally, pain subsides in 2 to 8 weeks. While the optimum treatment for the condition remains unproven, apart from rest, heel lift and foot orthoses can be effective in aiding recovery.
The Next Step
Perfect Balance Clinic has a strong background in the assessment and treatment of Sever’s disease and other sports-related overuse injuries. We can provide rapid access to our multi-disciplinary team of therapists who can carry out a thorough assessment of the condition and provide the most appropriate treatment regimens including orthotics and, where necessary, in combination with physical therapies and lifestyle recommendations such as appropriate rest.
If your patients are seeking relief from their heel pain and wish to return to their normal activities and sports in the shortest timeframe, a call to our clinic will result in a few questions which will help us fast track the patient to our most appropriate consultant or therapist. Patients can generally be seen within a day or so.
Have you read our free exclusive E-BOOKs available to download?
We have a variety of e-books available to download straight to your inbox, from exercise and sports advice sheets to specialist and general conditions. Please click here to visit the full page and take your pick!
Need more information? Why not contact us using the form below and we will get back to you as soon as possible
James, A. M., Williams, C. M., & Haines, T. P. (2016). Effectiveness of footwear and foot orthoses for calcaneal apophysitis: a 12-month factorial randomised trial. British journal of sports medicine, bjsports-2015.
Klose O., (2010), Do we really need radiographic assessment for the diagnosis of non-specific heel pain (calcaneal apophysitis) in children?, Skeletal Radiol., 39(4):359-61
Russell G., Volpe DPM., (2009), Keys To Diagnosing And Treating Calcaneal Apophysitis, Podiatry Today, 22-11
Shields, N. (2016). Wait and see, heel raise and eccentric exercise may be equally effective treatments for children with calcaneal apophysitis [synopsis]. Journal of physiotherapy, 62(2), 112.
Wiegerinck, J. I., Zwiers, R., Sierevelt, I. N., van Weert, H. C., van Dijk, C. N., & Struijs, P. A. (2016). Treatment of calcaneal apophysitis: wait and see versus orthotic device versus physical therapy: a pragmatic therapeutic randomized clinical trial. Journal of Pediatric Orthopaedics, 36(2), 152-157.