Sever's disease, also known as calcaneal apophysitis, is an inflammatory condition of
the growth plate of the heel (calcaneus). Sever's disease is seen during
periods of active bone growth, particularly between the ages of 10 and 14 years
old. Sever's disease is a self limiting condition,
meaning that all cases of Sever's disease will disappear once bone growth is
finalized and the growth plate of the heel closes. Skeletal maturity and closure of
the growth plate occurs for most boys at about 15-16 years of age.
Sever's disease is much more common in boys than
in girls. Most cases of Sever's disease are found in
children who are
moderately obese. Sever's disease can also occur in very active children.
Sever's disease is common in periods when activities for these children increase
such as twice daily football practices in the fall or at the onset of track
season in the spring.
Treatment of Sever's Disease
The treatment of Sever's disease depends upon the
severity of symptoms experienced by the patient. Most children can
continue with activities, including sports and begin a simple program of
stretching and heel elevation that will make a significant difference in heel
pain due to Sever's disease. If stretches and heel elevation is
unsuccessful in controlling the symptoms of Sever's disease, children should be
removed from sports and placed on restricted activities.
Severe Symptoms - Follow the directions for
mild and moderate symptoms. Children should be removed from sports activities
such as football, basketball, soccer or gym class. A
below knee walking
cast with a heel lift or in severe cases,
non-weight bearing fiberglass cast, may be indicated for 4-6 weeks. The cast should be
applied in a mildly plantar flexed position. Cam Walkers should not be
used for Sever's Disease unless they have a built in heel lift.
Apophysis - secondary growth plate.
Calcaneus - the heel bone.
Equinus - tightness in the calf and Achilles tendon limiting
normal range of motion of the ankle.
Itis - is a suffix derived from both Latin and
Greek that refers to inflammation.
the growing child, there are a number of different ways that
bones grow. In the calcaneus (heel bone), growth comes from two
separate growth plates. The lesser of the two growth plates is called the apophysis. The apophysis of the calcaneus is located between the
back and the bottom of the heel at that spot that hits the ground each time we
take a step. The Achilles tendon, which is the most powerful tendons in our
body, attaches to the proximal aspect of the apophysis. The plantar fascia
attaches to the distal aspect of the apophysis. Both the Achilles tendon
and plantar fascia place traction, or pulling on the growth plate and contribute
to inflammation of the secondary growth plate called apophysitis.
The calcaneal apophysis is very apparent on x-ray and continues to
grow until approximately age 12 in girls and age 15 in boys.
The calcaneus is very firm on the outside (cortical bone) and very soft and spongy on
the inside (cancellous bone). Load is applied to the calcaneus in two
ways. First, direct load is applied to the calcaneus with each step that we
take. This load is equal to or greater than the mass of our body. Second,
traction load is
applied to the calcaneus by the structures that are attached to it that pull
against the bone. Proximally, the Achilles tendon pulls on the calcaneus.
And distally, muscle and fascia resist the load applied to the calcaneus by the
The calcaneal apophysis is unique in that it is
affected by both of these types load bearing. The apophysis must accommodate
the pull of the Achilles tendon on the posterior heel and the resistance of the plantar fascia on
the bottom of the heel. In addition to the plantar fascia, several other soft
tissue structures pull on the plantar aspect of the heel including muscle and
ligaments. The pull of each of these soft tissue structures works much like a lever
arm and results in mechanical
load being applied to the calcaneal apophysis. For additional information
on how the leg and foot perform as a lever arm, please refer to our pages on
Interestingly, Sever's disease is found
in young boys who overload the apophysis with both body weight and mechanical
load. Most cases of Sever's disease are found in young boys (8-12 y/o) who are
overweight and have recently started a new physical activity. This
combined load of body mass and increased mechanical load results in an inability
of the growth plate to function normally. The heel pain experienced by
children with Sever's disease is an inflammatory response of the growth plate to
this increased load.
cases of Sever's disease show findings of
tightness of the calf muscle. How do you measure equinus? Equinus can be determined by measuring the range of motion of the ankle with the
knee flexed and extended. When the knee is flexed, the amount of equinus
of the soleus muscle is measured. With the knee extended, both the soleus
and gastrocnemius muscles are measured. Imaginary lines are established on
the long axis of the leg and the foot. By dorsiflexing the foot (toward
the body) an angular measurement is established between these two lines.
Normal range of motion of the ankle, to complete a normal gait cycle, is 10 to
15 degrees beyond 90 degrees. This means that the normal range requires
the ankle to dorsiflex to 90 degrees plus an additional 10 to 15 degrees.
An inability to complete this range of motion is termed equinus.
In summary, the biomechanical forces that contribute to
Sever's disease include both traction applied to the bone and the load applied
to the heel at the heel strike phase of the gait cycle. The pain
experienced by children with Sever's disease is simply due to a growth plate
that cannot keep up with the demands applied to it.
The symptoms of Sever's disease include pain that
tends to increase with activity. Pain is present
at the onset of activity and continues to increase with prolonged activity. Pain is in the body of the calcaneus.
Direct pressure, side to side on the medial and lateral walls of the heel is
most common location of pain. Swelling and redness are uncommon in cases of
Baxter's nerve entrapment -
entrapment of the 1st branch of the lateral plantar nerve of the posterior
Juvenile rheumatoid arthritis (JRA).
Retrocalcaneal bursitis (Albert's Disease) - this is the formation and
inflammation of a bursa at the back of the heel between the heel bone and Achilles tendon.
Sero-negative arthropathies such as Reiter's Syndrome.
Stress fracture of the calcaneus.
Tarsal Tunnel Syndrome.
Products Recommended for Severs Disease:
This article was written by Jeffrey A. Oster, DPM and last updated
2/8/13. No additional information is available for this topic.
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