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Heel Pain In Active Growing Children: Sever’s Disease

What this article tells you

  • What the most common cause of heel pain is in active young children
  • How to understand it
  • Presentation and expected findings
  • Differential diagnosis (things to look out for)
  • Management and treatment
  • Contacting our podiatrists

With the beginning of the new sports season we often seen an influx of children between the ages of 8-15 present with painful heels after their sports games. This is often related to a condition called Sever’s Disease.

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What is Sever’s Disease?

‘Sever’s’ or ‘Sever’s Disease’ is the irritation of the heel growth plate(s) and is the most common cause of heel pain in growing, active children.

Although ‘Sever’s Disease’ sounds a bit sinister, it is actually not a ‘disease’ and the prognosis is a self-limiting, benign syndrome which means it resolves when the growth spurt stops, without any long term complications. However, the symptoms during the flare up period can be quite painful and may need Podiatric management.

What is the cause?

Officially it is “A painful inflammation of the calcaneal apophysis due to repetitive trauma which aggravates the insertion of the Achilles tendon.”

I like to explain it a bit more simply as an overuse of the bone and tendons around the heel during a growth spurt. It occurs commonly in children with feet that roll in, and who are active and are growing.

How does it present, what are the symptoms?

Sever’s is commonly found in active children and it’s usually aggravated by walking, running or jumping. It is associated with pain in the back and sides of the heel over the growth plate area of the calcaneus (heel bone).

Typical history:

  • Pain experienced over the epiphyseal (growth plate) area of one or both heels
  • Children experiencing a growth spurt
  • Symptoms during the beginning of the sports season
  • Recently participating in explosive sport
  • Limp after exercise due to severity of pain
  • Increase in activity causing pain
  • Biomechanical abnormalities such as excessive pronation or restricted joints
  • Tight calves (triceps surae complex)
  • Slow onset of pain, with difficulty pinpointing events that could have caused the problem

Some other common characteristics of Sever’s:

  • Seen in both heels in 60% of cases
  • Usually manifests between 8-14 years old with a higher incidence in boys than girls but most common in boys aged 10-12 during a growth spurt
  • Quite often at the beginning of a sport season
  • More common in active children that participate in explosive sports such as soccer, basketball, softball, dancing and gymnastics

Expected findings:

  • A positive (painful) rearfoot “squeeze test” of the heel area
  • Unilateral or bilateral heel pain over the growth plate area
  • Limited ankle joint dorsiflexion
  • Tight gastrocnemius / soleus complex
  • Underlying biomechanical deformity of variable nature (for e.g. hyperpronation of the rearfoot)
  • Worsening pain with increased activity
  • Child may limp when walking
  • Swelling may be present but usually is mild. In long-standing cases, the child may have calcaneal enlargement (this is rare)
  • Plain x-ray of the heels can, but not often demonstrate inflammation of the heel(s)

Prognosis

  • Self-limiting, benign syndrome
  • There is no credible long-term research that exists for the sequel of untreated Sever’s disease, but it does cause limitations in participation and performance in sports
  • If left untreated this can cause major restriction in basic life activities until symptoms resolve when the growth plates fuse

To make a booking call 08 83634588 or contact us via our contact page.

Differential diagnosis – what we want to make sure we rule out!

The key characteristics of a differential diagnosis is having a negative squeeze test of the heel.

This then requires further investigation for other possible problems.

Traumatic events causing heel pain have key differentiating characteristics and good history taking is essential.

Further investigation with imaging such as x-ray, ultra sound and MRI is warranted to rule out more serious problems if deemed necessary.

Infective and internal causes of heel pain usually involve other key characteristics such as systemic symptoms including malaise (tiredness/ fatigue), a raise in core temperature, night pain, or generalised aches.

Treatment of Sever’s Disease

Stage 1 – Rest and recovery

  • RICE therapy (Rest, Ice, Compression, Elevation)
  • Anti-inflammatory medication (NSAID’s)
  • Taping
  • Modified rest or cessation of sports
  • Protective weight bearing using crutches etc (depending on severity)

Stage 2 – Increasing strength and biomechanical correction

Some examples:

  • Heel lifts
  • Taping
  • Anti-inflammatories (NSAID’s)
  • Orthoses (all types) or mobilizations to correct biomechanics
  • Specific stretching exercises
  • Plantar fascial stretching
  • Padding for shock absorption or strapping of heel
  • Complete shoe wear evaluation
  • Adequate shock absorption/rigid heel counter for shoes
  • Gradually increase activity levels (load management programs), including low-impact exercises such as cycling and swimming
  • Graduate back to sport, monitoring pain and symptoms.
  • With clinical signs of diminished pain or eliminated pain, increase the activity levels back to normal.

To make a booking call 08 83634588 or contact us via our contact page.

References:
Sever JW. Apophysitis of the os calcis. N Y Med J. 1912;95: 1025–1029.
Sharfbillig RW, Jones S, Scutter SD. Sever’s disease: what does the literature really tell us? J Am Podiatr Med Assoc. 2008;98:212–223.
Suneel B. Practical pointers on treating Sever’s disease in young athletes. Podiatry Today. 2011;24(10):20-21.
Chiodo WA, Cook KD. Pediatric heel pain. Clin Podiatr Med Surg 2010;27:355–67.
Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop 1987;7:34–8.
Rachel JN, Williams JB, Sawyer JR, Warner WC, Kelly DM. Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (sever disease)?. J Pediatr Orthop. 2011 Jul-Aug. 31(5):548-50.
Volpon JB, Filho GDC. Calcaneal apophysitis: a quantitative radiographic evaluation of the secondary ossification center. Arch Orthop Trauma Surg. 2002;122:338–341.

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