Document 6444864

American Family Physician
Sever's Disease and Other Causes
of Heel Pain in Adolescents
CHRISTOPHER C. MADDEN, M.D., University of Nebraska Medical Center, Omaha, Nebraska
MORRIS B. MELLION, M.D., Sports Medicine Center, Omaha, Nebraska
Sever's disease, or apophysitis of the calcaneus, is a common but frequently undiagnosed source of heel pain in young athletes.
This condition frequently occurs before or
during the peak growth spurt in boys and
girls, often shortly after they begin a new
sport or season. Sever's disease often
occurs in running and jumping sports, particularly soccer. Patients present with intermittent or continuous heel pain occurring
with weight bearing. Findings include a positive squeeze test and tight heel cords.
Severs disease cannot be diagnosed radiographically. The condition usually resolves
two weeks to two months after the initiation
of conservative treatment, which may
include rest, ice application, heel lifts,
stretching and strengthening exercises,
and, in more severe cases, nonsteroidal
anti-inflammatory drugs.
Sever's disease, or calcaneal apophysitis,
was first described in 1912 ns a cause of
heel pain and tenderness localized to the
posterior aspect of the calcaneus in physically active, overweight children and adolescents.'-^ Sometimes referred to as
Osgood-Shlatter disease of the heel, the
disease is a traction apophysitis occurring
at the secondary calcaneal ossification center that appears between the sixth and
eighth years in most children.'-'"*'
The secondary calcaneal center begins
with the ossification of several fragments
and eventually forms a vertically oriented
C-shaped growth plate at the posterior
border of the calcaneus.^** The insertion of
the Achilles tendon over the posterior and
inferior surfaces of the calcaneus subjects
the vertically oriented epiphysis to strong
November 1,1996
shearing forces during gastrocnemius contractions.'' " The disease occurs most commonly during the early part of the accelerated growth spurt. Fusion of the epiphysis
to the main body of the calcaneus occurs
between the ages of 12 and 15 years.''-'^
Sever's disease is now recognized as a
common source of heel pain in young
nonobese athletes. The condition responds
well to conservative measures.^^
Illustrative Case
A physically active nine-year-old boy
complained of insidious onset of bilateral
heel pain occurring after sports activity,
particularly soccer, over the previous two
years. The pain was associated with
weight bearing and had recently become
more constant. Current treatment consisted of ice applications.
On physical examination, the patient had
a mildly increased valgus of both lower
extremities. The insertion of the Achilles
tendon was markedly tender over the posterior calcaneus bilaterally. Mediolateral
compression (the "squeeze test") of the calcaneus anterior to the Achilles tendon
insertion elicited pain bilaterally. Heel cord
flexibility was significantly limited with the
knee extended. Radiographs demonstrated
increased density, irregularity, fragmentation and sclerosis at the calcaneal apophysis
Based on the child's history and the clinical findings, Sever's disease was diagnosed. The radiographic evaluation ruled
out other pathology. The patient was
referred to a physical therapist for a rehabilitative exercise program that focused on
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American Family Physician
Sever's Disease
improving flexibility. The use of Tuli's heel
cups was also recommended.
At the follow-up examination four
weeks later, the patient was greatly
improved. He was using his heel cups and
was playing soccer without difficulty. He
had no tenderness over the Achilles tendon insertion, a negative squeeze test, and
increased flexibility bilaterally. The patient
was instructed to continue rehabilitation
exercises and to come to the clinic for follow-up visits as needed.
Etiology
The etiology of Sever's disease has not
been established, but the main predisposing factors appear to be abnormal stress at
the epiphysis, biomechanica! abnormalities of the ftKit and overactivity with resultant microtrauma.^-'^^*'
Prepubertal long-bone growth often
exceeds muscle and tendon growth. As a
result, the flexibility of the heel cords
{Achilles, posterior tibial and peronea! tendons) is reduced, and ankle dorsiflexion
may diminish to less than 10 degrees. A
child may have congenital or acquired
shortening of the triceps surae.'^The plantar fascia may also be tight. These flexibility limitations may contribute to the occurrence of abnormal stresses at the calcaneal
apophysis with weight bearing.'* Acute
trauma, such as a violent heel strike in a
basketball player or a gymnast, may be a
triggering event.'*^
Biomechanical abnormalities that often
occur concomitantly with Sever's disease
include forefoot varus, hallux valgus, pes
cavus and pes planus.**'^^''' All of these
structural faults may have associated poor
shock absorption that may expose the heel
to abnormal forces."
Finally, the most significant etiologic factor in Sever's disease is overuse and microtrauma in sports that require repetitive
loading of the heel, such as soccer or running.^''•'•'' All dimensions of an increased
athletic workload, including duration,
intensity and frequency, may contribute to
the problem.
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FIGURE 1. R.Klioi;i-,iph ol thf It-ft lieol oi .^ uinv-
year-old boy with Sever's disease. AUhough the
radiograph demonstrates increased density,
irregularity, fragmentation and sclerosis at the
calcaneal apophysis, these radiographic findings
are considered to be within the normal range.
History and Presentation
The typical patient with Sever's disease
is a young athlete who is having a growth
spurt and who complains of intermittent
or continuous heel pain that occurs with
weight bearing shortly after the child
begins a new sport or season.''''" The problem usually develops in girls eight to 10
years of age and boys 10 to 12 years of age.
The heel pain, which can be bilateral or
unilateral, is usually precipitated by some
type of weight-bearing exercise.'' Pain is
usually absent when the child gets up in
the morning, increases with activity and
improves with rest. Hard surfaces and
poor-quality or worn-out athletic shoes
contribute to increased symptoms. The
child may have a liistory of direct trauma
or injury to the heel.^" The pain may
become so intense that the child must stop
athletic participation and must occasionally use crutches.'^
ln addition to soccer, sports frequently
associated with Sever's disease include
gymnastics, football, baseball, ice hockey,
tennis, figure skating, ballet, tae kwon do
and various running sports.''""'^ No longterm sequelae of Sever's disease have been
Physical Examination
The physical examination may reveal
forefoot varus, hallux valgus, pes cavus or
pes planus. Forefoot pronation is most
common.** '^'""^ Although gait may be normal, the patient may walk with a limp or
exhibit a forceful heel strike.'*'" Standing
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American Family Physician
FIGURE 2. Mediolateral heel compression, or the
"squeeze test," performed over the lower onethird of the posterior calcanetis. The test is positive if the compression elicits pain. (Top) Lateral
view. {Bottom) Posterior view.
Achilles tendon
Pre-Achilles fat pad,
Subcutaneous bursa
Retrocalcaneal
bursa
Epiphysis
Apophysis
Calcaneus —
Heel fat pad
Plantar fascia
FIGURE 3. Normal heel anatomy. Note that the apophysis is C-shaped and
occupies the posteroinferior aspect of the heel, with the Achilles tendon
inserting posteriorly.
November I, 1996
on tiptoe may aggravate the heel pain
(positive Sever's sign)."'^ Erythema,
swelling or other skin changes are uncommon and suggest different pathologic
processes/^-'^
Tenderness to palpation may be present
at or just anterior to the insertion of the
Achilles tendon along the posterior border
of the calcaneus.' Mediolateral heel compression, or the squeeze test, performed
over the lower one-third of the posterior
calcaneus elicits pain {Figure 2).''Heel pain
may be mild to severe, and it may prevent
weight bearing.
Heel cord flexibility is tested by passive
dorsiflexion of the foot with the knee in
extension. It is often reduced to less than
10 degrees, and testing may elicit pain.**-^^
Sever's disease cannot be diagnosed
radiographically.^ '^ The fragmentation,
sclerosis and increased density of the
apophysis that characterize Sever's disease
are considered normal radiographic findings'^ {Figure 3). The fragmented appearance occurs because the apophysis evolves
from several ossification centers.' As the
centers mature, they fuse together and
form a C-shaped growth plate located over
the posteroinferior border of the calcaneus.
The borders of the apophysis may appear
fluffy or well defined.^' As the apophysis
matures, calcifications appear that extend
to the main calcaneal body. Fusion of the
apophysis to the body takes place by
about 15 years of age, after which Sever's
disease no longer occurs."
Radiographs may rule out other possible
causes of heel pain, such as tarsal coalition,
fracture, bone cyst or tumor.-* Since patients
with Sever's disease have normal findings,
radiographs are indicated only for the differential diagnosis, for patients who do not
respond to conservative treatment and for
patients with an atypical presentation.
Differential Diagnosis
The diagnosis of heel pain is challenging
because many structures may be involved
{Figure 3). Conditions that can present as
heel pain in a young athlete are listed in
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Sever's Disease
TABLE 1
Differential Diagnosis of Heel Pain in Young Athletes
Conditioii
Presentation
Evaluation
Radiology
Sever's disease
Growing athlete, commonly
between 8 and 12 years old
Follows participation in a sport,
especially soccer
Unilateral or bilateral heel pain
that increases with activity,
particularly on hard surfaces
Squeeze test positive
Tight heel cords
Tenderness on palpation at the
insertion of the Achilles tendon
Sclerosis and fragmentation of
the calcaneal apophysis (findings
that are within the radiographic
normal range)
Plantar fasciitis
Usually unilateral
Pain and/or local tenderness over
the pmximal medial arch and/
or heel with weight bearing,
especially after rising in
morning
Pain sometimes relieved with
prolonged activity
Tenderness on palpation over
the medial calcaneal tubercle
(insertion ttf the plantar fascia)
Diffuse medial heel and/or arch
pain with palpation
Often, tight heel cords
Radiograph may show anteroinferior calcaneal spur
Achilles tendinitis
Stiffness (early) of the Achilles
tendon, which progresses to pain
(later) with continued activity
Crepitus or swelling over the
Achilles tendon
Tenderness and/or thickening on
palpation over the body
(middle section) of the Achilles
tendon
Tight heel cords
Crepitus with passive range of
motion
I'ain increases with hopping
Plain radiograph; loss of sharp
anterior interface with pre-Achilles
fat pad; calcification or osteophytes
Ultrasound: tears, calcification
CT and MRl scans: tears, thickening
or degeneration of tendon
Retrocaloaneal
bursilis
Aching pain and/or swelling
anterior to the Achilles tendon
following exercise
Tenderness on palpation and/or
swelling anterior to the Achilles
tendon in the retnicalcaneal
Radiograph may show loss of
sharp definition of lucent
(increased opacity) retnKalcaneal
recess
Posterior superior enlargement of os
calsis ("hatchet heels") may be
present
Calcaneal stress
fracture
Participation in repetitive jumping
and/or running sports
Localized heel pain at fracture site
Mild swelling
Pain with mediolateral
aimpression of calcaneal lx)dy
Local pain at fracture site on
palpation
Radiograph may be normal or may
indicate periosteal new bone
formation or fine fracture line
Bone scan can be used if the
radiographic findings are negative
Tarsal coalition
Teenager or preteen complaining
of diffuse arch pain
Often, a liistory of recent ankle
sprain or an increase in training
intensity
Rigid flat foot
Subtalar tenderness
Decreased subtalar mobility
Occasionally, rigid peroneal
spasm
Radiograph (oblique view is often
helpful): "bars" between tarsal
bones
CT scan (definitive): union of tarsal
bones
Tarsal tunnel
syndrome
Aching or burning pain and
paresthesia (medial or lateral)
that increase with weij^ht bearing
Symptoms may coexist with
plantar fasciitis
Often, hyperpronated or flat feet
Painful area over the site of
impingement
Fo.sitive Tmel's sign: tapping at
impingement site (behind or
below medial malleolus) causes
pain over the plantar nerve
distribution
Radiographs normal
Can perform EMG/NCT
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TABLE 1 continued
Condition
Presentation
Evaluation
Radiology
Systemic disease
(ankylosing
spondylitis, Reiter's
syndnime, juvenile
rhc'uniatoid arthritis)
Tumor
Disease-specific symptoms
Plantar fasciitis-like symptoms
Often bilateral
Morning stiffness
Complete history and physical
examination with comprehensive
review of systems
May order ESR, RF, HLA B27,
urinalysis
Radiograph: targe, fluffy heel spurs
and enisions of the posterosuperior
cortex of the calcaneus
Refer to individual diseases for
specific findings
Pain of long duration
Night pain
Fever, malaise and/or anorexia
Complete history with a review
of systems
CBC, ESR, radiographs, bone scan
Radiograph: radiolucent mass, often
not crossing joint margins; cystic
mass
Bone scan may be used
Infection
Puncture wound
Night pain
Erythema and/or swelling
Fever, malaise and/or anorexia
Enlarged posterosuperior
calcaneal prominence
Rubbing of footwear may increase
pain
Local pain
History of forceful heel impact
Heei pain that Increases with
activity
Walking barefoot or after rest is
painful
Often overweight
Tenderness on palpation
Soft tissue signs
CBC, ESR
Radiograph: normal or soft tissue
swelling
Posterior calcaneal prominence
Subcutaneous bursa may be
tender to palpation
Radiograph (oblique view is often
helpful): pt>ssibly, exostosis
between the Achilles tendon and
the calcaneus
Swelling, ecchymosis, tenderness
on palpation of the injured area
Pain on palpation of heel pad
Pain relief while on tiptoe
Radiograph: normal or soft tissue
swelling
Pump bump
(runner's bump).
or calcaneal
exostosis
Contusion
Heel fat pad
syndrome
Noncontributory
CT - computed tomography; MRt = magnetic resonance imaging; EMC/NCT = clectromyography/newe conduction test; ESR = erythrocyte sedimentation rate; RF' = rheumatoid factor; HI A B27 ^ human leukocyte antigen B27 (blood test for ankylosing spondylitis and Reiter's syndrome); CBC = complete blood count.
Derived from references 2,3,10,12,14.15
and 18.
Table 1, along with factors that can help differentiate among theseproblems.^-^'"'^'^'^'"
Management
The initial treatment of Sever's disease
consists of rest, ice application, use of heel
Ufts, and stretching and strengthening exercises. Activities that cause symptoms
should be stopped, k e should be applied to
the heel for 25 minutes three times a day."
Heel lifts (one-fourth to one-half inch) or
viscoelastic heel cups can be used to decrease impact shock.^'^'*'^* Rehabilitation
under the supervision of a physical therapist would include heel cord flexibility and
dorsiflexor strengthening exerdses.^""
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Analgesics may not be warranted in
mild occurrences, but in more severe cases
or if symptoms do not improve, nonsteroidal anti-inflammatory drugs may be
effective in reducing pain. The patient
should also be instructed to wear supportive shoes with a solid heel counter and to
avoid walking barefoot.^•''^ If the pain is
severe enough to cause a limp, crutches
may be used for symptom control.'-^ In
addition to using heel cups and pads during acute stages, orthotics may be used to
correct significant biomechanical abnormalities after symptoms resolve.'^
Follow-up should take place in two to
four weeks.^"-^^Rarely, resistant cases of
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Sever's Disease
Sever's disease may require the use of a
short leg cast for two to four weeks.""'
Corticosteroid injections are not recommended.""'"'Nighttime dorsiflexion splints,
often a useful adjunct in the treatment of
plantar fasciitis, may help relieve symptoms and may help maintain flexibility
throughout the growth period of preadolescent athletes.'•'"*'''-'' lf the symptoms have
not improved significantly on foUow-up, if
there is an unusual presentation or if the etiology is unclear, calcaneal radiographs may
be taken to rale out other pathology.''^
Symptoms usually resolve in a few weeks
to tu'o months after tlierapy is initiated.^'''
With proper treatment, most cases of
Sever's disease resolve completely.'*' Return
to activity may take place only when symptoms allow comfortable participation.^
Stretching and strengthening during
rapid growth spurts may significantly
reduce the incidence of Sever's disease.-'
Good-quality athletic shoes with a shockabsorbent sole and firm heel counter will
provide adequate support and help prevent injury. If a patient will be returning
to sports after recovery, stretching and
icing after activity may help prevent
recurrence.''-'"*
A patient information haiidont oti Sever's disease
is provided ou page 2U04.
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The Authors
CHRISTOPHER C. MADDEN, M.D.
is a family practice resident <it the University of Nebraska
Medical Center, Omaha. Dr. Miidden received his medical degree from the University of Nebrnska Schmil of
Medicine, Omaha. He designed and taught "Healthy
Lifestyles," a program to introduce dnd encourage basic
fitness and health principles in young Omaha teenagers.
14.
15.
16.
17.
MORRIS B. MELLrON, M.D.
is medical director at the Sports Medicine Center,
Omaha, and clinical associate professor in the
Department of Family Practice and Orthopedic Surgery
at the University of Nebraska Medical Center. He also
serves as adjunct associate professor for the School of
Health, Physical Education, and Recreation at the
tJniversity of Nebraska, where ho is the team physician
for men's and women's sports. Dr. Mellion is a past president of the American Academy ol Family Fhysidans.
18.
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Address conesptmdetice to Morris B. Mellioii, M.D., Medical
Director. Sports Medicine Center, 2255 S. J32nd St.. Omaha.
NE 68144.
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