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Sever Disease

 Sever Disease


Sever disease is a traction apophysitis at the insertion of the Achilles tendon and is a common cause of heel pain in the athletically active child. It’s also referred to as calcaneal apophysitis.

Bilateral sever disease is present is 61% of cases.

Sever Disease is more common in boys than in girls, and typically appears between age 10 and 14 years, prior to closure of calcaneal apophysis and just before or during a growth spurt.

It’s more commonly seen in immature athletes participating in running & jumping sports.

See Also: Osgood Schlatter Disease
calcaneal apophysitis
Calcaneal Apophysitis

Related Anatomy

The calcaneal apophysis serves as the attachment for the Achilles tendon superiorly and for the plantar fascia and the
short muscles of the sole of the foot inferiorly.

This os calcis secondary center of ossification appears at 9 years of age and usually fuses at 16 years of age.

calcaneal apophysis anatomy
Calcaneal Apophysis Anatomy

Sever Disease Etiology

Factors involved in the etiology of Sever disease include

  1. Beginning a new sport or season,
  2. Foot pronation,
  3. A tight gastrocnemius–soleus complex.

Young gymnasts and dancers are particularly susceptible to this condition because of their repetitive jumping or landing from a height.

The tight Achille tendon is usually associated with a recent growth spurt and is not related to a specific injury.

The apophysis is the weakest point in the muscle-tendon-bone-attachment.

Sever Disease Symptoms

The location of the pain differs from that of plantar heel pain in that its focal point is more posterior than it is plantar.

The pain increase with activity and is also aggravated by standing on tiptoes (Sever sign).

Other symptoms such as warmth, erythema and swelling can be present at the Achilles insertion on the heel.

Physical examination may reveal a tightness of Achille tendon and positive squeeze test (compression over the tuberosity of the calcaneus).

See Also: Homans Sign

Sever’s Disease Radiology

It’s recommended to obtain a bilateral imaging to delineate osseous abnormality versus normal variants in the individual patient.

Although radiographs are often normal, sclerosis or fragmentation of the apophysis may be seen on plain radiographs.

MRI can show inflammation of apophysis.

Differential Diagnosis

Differential Diagnosis of Sever Disease include the following cases:

  1. Achilles Tendon Injuries,
  2. Calcaneus Fractures,
  3. Osteomyelitis,
  4. Tarsal Condition.

Sever Disease Treatment

Non-operative treatment of severe disease includes:

  1. Activity modification,
  2. Ice application before and after sporting activity,
  3. NSAIDs,
  4. Shortening of the gastrocnemius-soleus group using heel cups or heel wedges, and avoiding barefoot walking until becoming asymptomatic.
  5. A Sever Disease rehabilitation regimen is essential and should include heel cord stretching, Gastrocnemius stretching and dorsiflexor strengthening.

If the pain does not respond to conservative treatment, a walking boot or short leg cast may be used for short-term immobilization.

The Symptoms are usually self limited, improvement is achieved within 6 to 12 months and a complete resolution of symptoms with apophyseal closure.

There is no role for injection therapy or surgical intervention in the treatment of Sever disease.

There are no long-term complications, and the prognosis is excellent. 

heel cups
Heel Cups for treating Sever Disease

References

  1. Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928
  2. Omey ML, Micheli LJ. Foot and ankle problems in the young athlete. Med Sci Sports Exerc. 1999 Jul;31(7 Suppl):S470-86. doi: 10.1097/00005768-199907001-00008. PMID: 10416548.
  3. Howard R. Diagnosing and treating Sever’s disease in children. Emerg Nurse. 2014 Sep;22(5):28-30. doi: 10.7748/en.22.5.28.e1302. PMID: 25185924.
  4. Davison MJ, David-West SK, Duncan R. Careful assessment the key to diagnosing adolescent heel pain. Practitioner. 2016 May;260(1793):30-2, 3. PMID: 27382917.
  5. James AM, Williams CM, Haines TP. Health related quality of life of children with calcaneal apophysitis: child & parent perceptions. Health Qual Life Outcomes. 2016 Jun 24;14:95. doi: 10.1186/s12955-016-0497-4. PMID: 27342767; PMCID: PMC4921004.
  6. Stanitski CL. Management of sports injuries in children and adolescents. Orthop Clin North Am. 1988 Oct;19(4):689-98. PMID: 2971909.
  7. Meeusen R, Borms J. Gymnastic injuries. Sports Med. 1992 May;13(5):337-56. doi: 10.2165/00007256-199213050-00004. PMID: 1565928.
  8. Crawford F. Plantar heel pain and fasciitis. Clin Evid. 2004 Jun;(11):1589-602. Update in: Clin Evid. 2005 Jun;(13):1533-45. PMID: 15652071.
  9. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.

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