What is Sever’s Disease?
Sever’s disease or also called calcaneal apophysitis is a condition involving heel pain due to overuse and repetitive trauma to the growth plates in the heels, specifically in the calcaneus. It is commonly experienced by growing athletes or children aged 7 to 15 years. The most commonly affected age groups are those aged 10 to 14 years.
The term came from the person who first characterized it, JW Sever. He was able to study and describe the disease in 1912. Athletes or people who engage in high impact activities involving the foot may experience tear and inflammation in the calcaneus because of lack of stretching. Other factors may also be considered in its development.
The feet usually grow during puberty. When this happens, the bones on the feet usually grow at a faster rate than the tendons and the muscles leading to a tighter and overstretched muscles and tendons. Because of this, there is less flexibility of the heel area. When children or young athletes engage in weight bearing activities, it may cause too much pressure in the heels injuring the calcaneus, leading to Sever’s disease. The calcaneus is the bony area of the heels where the Achilles tendon attaches.
Sever’s disease is not common in teens more than 15 years of age because the heels have already attained physical maturity. Sever’s disease is associated with overuse injury on the tendons and bones in the heels. Most common causes of the disease include those that involve the feet such as playing soccer, running, gymnastics and jumping. It may also develop when children use ill-fitting shoes that compress the heels as well as those who tend to overpronate. Engaging in activities without adequate warm up stretching of the foot may also cause Sever’s disease.
Sever’s Disease Image
Image source: footlogics.com.au
Symptoms & Signs of Sever’s Disease
Symptoms of Sever’s disease arise because of the injury and inflammation on the heels. These include:
Pain and Tenderness on the Heels
Pain is a classical symptom of Sever’s disease. As a result of tear and injury to the calcaneus, the inflammatory response is stimulated. This produces chemical mediators such as histamine and prostaglandin, leading to cardinal signs of inflammation such as pain, redness, swelling and heat. The pain is more severe during activities such as walking, running, jumping or any activities involving the feet. Pressing the heels may also cause tenderness because of pressure of the heel bone on the surrounding tissues.
Swelling in the Heels
Swelling is also evident because of increased permeability of blood vessels leading to the movement of fluids from the blood into the interstitial space as a result of the inflammatory process.
Difficulty in Walking
Patients may walk tiptoed because of pain when the heels touch the floor. Different tendons are also attached to the heels, which causes reduced flexibility of the affected foot leading to problems in ambulation.
The feet may become flaccid and weak because of damage to the heel. There may be problems on dorsiflexing the foot wherein the affected foot may assume plantar flexion all the time.
Diagnosis of Sever’s Disease
The diagnosis of Sever’s disease is made by physical examination as well as imaging studies to determine deformities in the foot. Imaging techniques may involve:
X-ray is the most common diagnostic test for Sever’s disease. It is able to show deformities in the heels. However, some conditions may need further imaging test to ascertain diagnosis.
X- ray imaging showing Sever’s Disease
Image source: myfootdr.com.au
MRI is rarely done when X-rays provide inconclusive results. It is also able to detect other problems in the tendons.
Treatment of Sever’s Disease
Treatments for Sever’s disease include:
Rest – Rest is the initial treatment following the acute phase of the injury. Rest is employed to prevent further injury and allow the tendons to naturally heal. However, rest should only be limited to one to two days because the child needs to initiate stretching exercise for improved flexibility and functioning.
Ice packs – Icing is also employed because it causes vasoconstriction thereby reducing swelling. It also reduces pain because of localized numbing effect of ice. Ice packs are especially important following the injury to prevent severe swelling. Ice pack should be applied over the affected heal for 15 to 30 minutes three times a day.
Compression – Compression is also helpful to immobilize the area and prevent further swelling. Foot splints may be placed around the lower leg just above the heels and up to the foot to maintain a normal foot position and prevent foot drop.
Foot elevation – Elevating the foot improves venous return, thereby also improving arterial blood flow. Improving venous return from the foot specifically aids in reducing swelling.
Exercise – Stretching exercises should be started within two days of injury to improve flexibility of the muscles and the tendons. Stretching exercises involving the foot includes:
- Calf Stretches – Stretching the calf is done to provide adequate support to the lower legs and also improves the flexibility of the ankle tendon. Do this by standing with the hands on the wall while stretching one foot towards the back. Keep the foot flat on the floor. Maintain the position for 20 seconds. Do these two times a day.
- Plantar fascia stretch – The plantar fascia is a fibrous tissue located at the sole of the foot and is connected on the calcaneus of the heels. This exercise involves maintaining the foot dorsiflexed by flexing the foot towards the shin.
- Hamstring and shin stretch – Sit with the legs across the floor. Keep the knees flat as you bend the foot towards the shin. This stretch allows the hamstring muscles as well as muscles on the lower leg to strengthen in order to provide support to the foot.
Shoe Modification – Choose shoes that are well fitting in order to prevent injury to the heels and allow for faster healing.
Foot Orthoses – Feet orthoses are devices placed on the shoe to provide heel support. Heel pads may be placed to prevent tension on the heels.
Foot orthoses for heel support
Physical Therapy – Physical therapy is also employed to allow for maximum range of motion of the foot and allow the child to regain normal foot movement.
Medications – Anti-inflammatory medications such as ibuprofen and naproxen may be given to reduce pain and inflammation.