What is Calcaneal Apophysitis or Sever’s Disease?
Calcaneal apophysitis, or Sever’s disease, is a painful inflammation of the growth plate in the heel. It typically affects children between the ages of 8 and 14 years old because the heel bone (calcaneus) is not fully developed until at least age 14. Until then, new bone is forming at the growth plate (physis), a week area located at the back of the heel. When there is too much repetitive stress on the growth plate, inflammation can develop.
With proper treatment, Sever’s disease usually resolves within 2 months with no long term effects on the child.
Sever’s disease, although not a true disease, is the most common cause of heel pain in children, and it can occur in one or both feet. Heel pain in children differs from the most common type of heel pain in adults. While heel pain in adults usually subsides after a period of walking, pediatric heel pain generally doesn’t improve in this manner. In fact, walking typically makes the pain worse.
The inflammation occurs at the point where the Achilles tendon attaches to the calcaneus bone, the large bone that makes up the heel of the foot.
Overuse and stress on the heel bone through activity or sports are major causes of sever's disease. The heel's growth plate is sensitive to repetitive running and pounding on hard surfaces, resulting in muscle strain and inflamed tissue. For this reason, children and adolescents involved in soccer, track or basketball are especially vulnerable. Other potential causes of sever's disease include obesity, a tight Achilles tendon and biomechanical problems such as flatfoot or a high-arched foot.
Symptoms of Sever’s disease include the following:
- Pain in one or both heels, usually at the back
- Difficulty walking, walking with a limp, or walking on tiptoes
- The heel may appear red, swollen and warm
- Pain when the heel is squeezed on both sides
- Usually seen in physically active children between 9 and 14
- Symptoms improve with rest and worsen with activity
Sever's Disease can be caused by the following:
- Repetitive stress resulting from sports that involve running and jumping.
- Standing for extended periods of time causing constant pressure on the heel
- Poor-fitting shoes and improper footwear
Risk factors for developing Sever's Disease include the following:
- Physically active children at the onset of puberty who are involved in running and jumping activities are at increased risk of developing Sever’s disease.
- Short leg syndrome, a condition where one leg is shorter than the other, can cause pulling of the Achilles tendon leading to Sever’s disease.
- Being overweight creates more pressure on the growth plate.
- Flat arches, high arches, or pronated foot, where the foot rolls inward, can cause tightness of the Achilles tendon thereby increasing pressure on the heel.
Your physician will diagnose Sever’s disease based on medical history and physical examination. Your doctor performs a physical examination of the heel to assess for swelling, redness, and localized tenderness. Your doctor may perform a squeeze test to assess whether the pain occurs when squeezing the back part of the heel from both sides.
Although Sever's Disease cannot be seen on an X-ray, your physician may order them to rule out other problems such as a fracture.
The goal of treatment is to relieve the pain. Treatment options include:
Any activities that cause heel pain should be stopped until the pain resolves. Adequate rest relieves pressure on the heel bone reducing swelling and tenderness.
Ice or cold packs
Ice wrapped in a towel should be applied to the injured heel for 20 minutes 3 times a day to reduce swelling.
An elastic wrap or compression stockings may be used to help reduce the swelling and pain. Elevating the heel above the heart level also helps with the swelling.
Calf stretch, heel cord stretch, and hamstring stretch are performed to stretch and strengthen the leg muscles and tendons on the back of the leg. These should be done 2 -3 times a day, holding each stretch for 20 seconds.
Strengthening exercise using a bungee cord or rubber tubing is also performed 2-3 times a day to strengthen the muscles on the front of the shin. The child should sit on the floor keeping the affected leg straight. One end of the bungee cord is tied around a table leg and the other end around the child’s toes. Then the child moves back just far enough to stretch the cord. The foot is slowly bent towards the child’s body, then the foot is pointed towards the table in the opposite direction.
Over-the-counter NSAIDs may be taken to reduce the pain and swelling. Never give children aspirin due to the risk of a serious illness called Reyes Syndrome.
Orthotic devices such as heel pads, heel lifts or heel cups are recommended in children with pronated feet, and flat or high arches. These provide cushion to the heel and reduce the strain on the Achilles tendon.
In severe cases, a short leg cast may be applied for 4 to 6 weeks to immobilize the foot so that it can heel.
Sever’s disease can be prevented with the following recommendations:
- Maintain a healthy weight
- Wearing good quality, well-fitting shoes with a shock-absorbent sole to reduce pressure on the heel
- Avoid heavy or high heeled shoes
- Avoid excessive running on hard surfaces
- Stretching exercises and ice application should be continued after sports activities to prevent recurrence of Sever’s disease.