Key signs of Sever’s Disease (Heel Pain)

Pain in heel – usually when weight bearing.

Adolescents aged 7-14 years, especially those who are active in sports.

Overview

The calcaneal tendon (achilles tendon) is the strongest tendon in the body, and it connects both the gastrocnemius and soleus, known as the calf muscles, to the calcaneus (heel bone) – the largest bone in the foot.

An apophysis is a normal outgrowth of bone that usually forms an insertion point for a tendon or ligament. There are several apophyses throughout the body but, the one relevant to this condition is at the posterior section of the calcaneus (back of the heel bone). This is the point at which the calcaneal tendon inserts into the calcaneus. The suffix ‘itis’ denotes inflammation. An apophys’itis’ is therefore inflammation at the apophysis.

Sever’s Disease is an apophysitis of the calcaneus, and is the most common cause of heel pain in growing young adults.

Causes

  • The calf muscles are used during activities like walking, running and jumping. Commonly, sports such as basketball, running and gymnastics cause the most heel cord loading and trauma to the apophysis.
  • Around the age of 7, the calcaneal apophysis begins development of independent ossification (hardening), and usually completes around the age of 14.
  • During growth spurts, bones become larger. As the bones develop, the muscles and tendons that are attached to them experience increased tension. In this case, the lengthening of the tibial bone in the lower leg will stretch the calf muscles and cause the most tension at the calcaneal insertion point.
  • Biomechanical abnormalities and overuse increase the likelihood of developing Sever’s Disease.

In short, the believed cause of Sever’s Disease is: A weaker structure of the developing adolescent apophysis receiving increased tension due to growth, and further aggravated by sporting activities and / or biomechanical abnormalities.

Presentation

  • Sever’s usually presents in young athletes before or during peak growth spurt and when activity is suddenly increased such as at the beginning of a sporting season.
  • Pain experienced at the apophysis and not the calcaneal body – Pain at the calcaneal body could indicate stress fracture and / or osteomyelitis.
  • Limp or pain on going up onto tip toes, which tenses the calf muscles. Pain on dorsiflexion of the foot (moving foot upwards towards the body), which stretches the calf muscles.

Treatments

Orthotics – Orthotics with a heel lift will shorten the achilles tendon and therefore reduce tension and inflammation at the apophysis when walking / running. This temporary conservative treatment should allow healing to take place without interruption, and reduce symptoms. This should also be accompanied by daily calf stretches.

Icing – Regular short applications of ice to the injured area should reduce swelling. Often, a bag of frozen vegetables wrapped in a cloth and applied to the site for around 10 minutes is recommended. There is a danger of damaging the body’s tissues if ice is applied for too long. Therefore, keep applications short in time. A cloth will prevent the cold item sticking to the skin.

Calf / achilles stretches – Growth spurts and healing can tighten up the calf muscles and achilles tendon. It is helpful to regularly stretch the area.

Anti-inflammatories – Inflammation can be reduced during the acute phase by taking non-steroidal anti-inflammatory drugs (NSAIDs). Usually taking daily for 1 week is sufficient – always read the drug label and be aware that taking for more than a week is usually not recommended as they can irritate the stomach.

Shockwave therapy – Mechanical (not electrical) shock waves are transmitted through the skin to the injured part. These increase blood flow to the area and accelerate the healing process.

Please contact our clinic for further information or to arrange an appointment.

Sources

Baxter, D. and Porter, D. (2008). Baxter’s the foot and ankle in sport. 1st ed. Philadelphia, PA: Mosby/Elsevier.

Logan, A. and Rowe, L. (1995). The foot and ankle. 1st ed. Gaithersburg, Md.: Aspen Publication.

Maffulli, N. and Easley, M. (2013). Minimally invasive surgery for achilles tendon disorders in clinical practice. 1st ed. London: Springer.

Marchick, M., Young, H. and Ryan, M. (2015). Sever’s Disease: An Underdiagnosed Foot Injury in the Pediatric Emergency Department. Open Journal of Emergency Medicine, 03(04), pp.38-40.