Sever's Disease - A Common Youth/Adolescent Injury
Sever’s Disease or Calcaneal apophysitis is a condition that causes heel pain most commonly affecting children and teenagers with immature (growing) skeletal bone. Young individuals experiencing a rapid growth spurt or engaging in sports activities that involve running and jumping can experience heel pain, which then subsides following rest or inactivity.
Sever's Disease (SD) is a transitional musculoskeletal disorder marked by inflammation of the growth plate in the calcaneus, the heel bone. The condition carries Dr. James Warren Sever's name, who was the physician who initially reported it in 1912. SD commonly affects individuals between the ages of 8 and 14, with symptoms of the condition usually appearing during times of rapid growth. Essentially the condition frequently occurs when bone growth occurs at a greater rate than that of the muscles and tendons, to cause additional strain on the growth plate. The consequent heel pain and discomfort may significantly limit capacity to engage in sports and other physical activities.
Let's Look at the Anatomy
The largest bone in the foot, the calcaneus, or heel bone, is essential for both weight bearing and movement. The Achilles tendon, which connects the calf muscles to the heel bone, is located behind the calcaneus. Running, jumping, and walking all put force on the heel bone through the Achilles tendon. The growth plate at the back of the heel is especially prone to injury in young individuals because of its continued development and relative vulnerability in comparison to the surrounding components.
Contributing Factors to SD
Activity level and age are factors in SD where typically the condition manifests in the preteen years, particularly when engaging in physical activity. Major risk factors contributing to inflammation and pain include:
- Changes in height and weight during development
- Change in level of physical activity - increase in volume, intensity, or frequency
- Load-bearing sports and activities, such as football, netball, gymnastics, and running
- Other contributing factors include switching to low-heeled footwear such as football boots where the Achilles tendon comes under more strain from the additional load to the calcaneal apophysis site
- Foot posture: flat feet, high arches or tight calf muscles
- Poor heel cord flexibility or dorsiflexion weakness may be observed as predisposing risk factors
What are the Symptoms of SD?
SD can affect one or both heels with distinctive signs and symptoms:
- Heel discomfort particularly when sprinting or jumping.
- Pain worsens after working out sessions.
- Limping
- Redness and swelling in the heel area.
- Foot stiffness upon waking.
- Pain while applying pressure to both sides of the heel
- Tendency to tiptoe as a compensating reflex to reduce heel discomfort.
SD Diagnosis
SD diagnosis is primarily clinical however imaging studies may be required. Clinical examination typically demonstrates tenderness and mild swelling at the Achilles insertion on the heel. Physical examination may indicate pain with passive ankle dorsiflexion and again reproduced with manual medial and lateral compression of the posterior calcaneus. Pain is aggravated by standing on tiptoes—a phenomenon known as the Sever sign.
Early Phase Management
Early diagnosis for SD is important to reduce discomfort and inflammation. Reducing physical activities that aggravates symptoms is an important first step. Conservative treatment encompasses rest and icing.
Rehabilitation - The Importance of Load Management & Injury Prevention
Research suggests that managing SD to avoid recurrence requires rehabilitation to restore calf muscles, Achilles tendon and surrounding tissues to previous levels of flexibility, strength, and proprioception once initial symptoms reduce. Exercises for strengthening the muscles, especially those that work the calf muscles eccentrically, can help reduce strain on the growth plate. Exercises for balance and coordination, which are part of proprioceptive training, can increase body awareness and control and lower the risk of injury when engaging in physical activity.
An essential part of Sever's Disease recovery however is load management. A gradual return to sports and other physical activities as well as a steady increase in activity level to help avoid overloading the heel and exacerbating symptoms. To that end, it is critical for the affected individual to pay attention to signals of pain and discomfort. Reducing the time or intensity of exercise, for example, can help avoid further irritability of the growth plate and facilitate recovery. The team at GymTherapy can facilitate the creation of a rehabilitation and activity plan that addresses SD symptoms and their effects.
The value of immediate intervention for SD can help prevent long-term issues. This may include injury prevention programs that emphasise appropriate warm-up and cool-down techniques, strengthening and stretching exercises, and a gradual increase in activity levels to avert SD symptoms. During strenuous exercises, appropriate footwear with sufficient cushioning and support can also help absorb shock and lessen stress on the heel. Frequent growth monitoring and biomechanical evaluations can detect risk factors early on, enabling preventative measures and proactive intervention.
To Finish
Although Sever's Disease frequently manifests during periods of rapid development and high physical activity, often causing heel discomfort in young individuals, it is a treatable condition with early rehabilitation and management of the condition key to minimising discomfort and returning to robust activities.
Treatment protocols include prescribed rehabilitation and exercise, GymTherapy can ensure the best outcome for your active young athlete. Our holistic approach includes early intervention, rehabilitation, load management, and injury prevention methods.
If your young adolescent is experiencing symptoms and are dealing with pain or discomfort in the heel region, consider a physiotherapy consultation for tailored guidance and treatment.
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References
SmithJM, Varacallo M. Sever Disease (Calcaneal Apophysitis) [Updated 2024 Jan 11].In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928/
Davison,Martin J et al. “Careful assessment the key to diagnosing adolescent heelpain.” The Practitioner vol. 260,1793(2016): 30-2, 3.
James,Alicia M et al. “"Effectiveness of interventions in reducing pain andmaintaining physical activity in children and adolescents with calcanealapophysitis (Sever's disease): a systematic review".” Journal of foot and ankle research vol. 6,1 16. 3 May. 2013,doi:10.1186/1757-1146-6-16
Launay,F. “Sports-related overuse injuries in children.” Orthopaedics & traumatology, surgery & research : OTSR vol.101,1 Suppl (2015): S139-47. doi:10.1016/j.otsr.2014.06.030
Gao,Yan et al. “Radiographic study of Sever's disease.” Experimental and therapeutic medicine vol. 20,2 (2020): 933-937.doi:10.3892/etm.2020.8796
