Sever's Disease
Radiology Cases in Pediatric Emergency Medicine
Volume 1, Case 20
Erin A. Nakano, MD
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
A 10 year male presents to the acute care clinic with
a 3 month history of intermittent right heel pain. There
was no inciting specific injury that he could recall. He
first noticed the pain while playing basketball. The heel
pain would worsen with running and playing sports,
especially basketball and soccer. The longer he
played, the worse the pain would become. There was
no history of fever or any other bone or joint complaints.
Exam: T37.0, P81, R24, BP 126/78. He was of an
average size for age, alert, active, in no discomfort.
The extremities were without swelling or deformities.
There was no erythema or evidence of external
infection over the heels. There was moderate
tenderness to compression over the right posterior heel
at the insertion of the achilles tendon (calcaneal
apophysis). Both ankles and all other joints were
normal. He ambulated normally and he could jump up
and down without difficulty or pain.
Radiographs of the right foot were obtained.
View radiographs: Oblique view.
Lateral view.
The main point of interest in this case is the heel at
the achilles tendon insertion. An AP view of the foot
was excluded from this case since it was normal and
the heel was not visible due to superimposition of other
bones.
The oblique view shows crescent-shaped lucencies
over the posterior calcaneus in the area of concern.
These lucencies represent the growth plate viewed
obliquely. The lateral view shows the physis in a truly
lateral view. These radiographs of the foot are normal.
Discussion and Teaching Points:
The most common cause of heel pain in adolescents
is calcaneal apophysitis (also known as Sever's
disease). Radiographs of the heel are felt to be normal
as they were in this patient, although some authors
have disagreed with this point.
An apophysis is a growth plate that does not
contribute to the length of the bone. The achilles
tendon inserts in the calcaneal apophysis. The patellar
tendon inserts into the tibial tuberosity apophysis. The
growth plate is weak and subject to micro-injury if there
is excessive force placed on the growth plate.
Developmental changes of the calcaneal apophysis
include the onset of ossification at an average age of 8
years in boys and 6 years in girls. For 2 to 3 years
thereafter, the ossification appears irregular and there
may be deep narrow clefts segmenting the apophysis.
Similar to Osgood-Schlatter disease (tibial tuberosity
apophysitis), Sever's disease (calcaneal apophysitis) is
an overuse syndrome frequently seen in adolescents in
their growth spurt, who are physically active. The most
common sports found to exacerbate the heel pain are
soccer, basketball, gymnastics, and baseball. Sports
that involve sprinting with cleated shoes result in the
most force exerted by the ankle flexors on the calcaneal
apophysis. Examination of the heel typically reveals
tenderness to compression of the medial and lateral
sides of the calcaneal apophysis and decreased
dorsiflexion of the ankle without any swelling or
erythema. Findings are bilateral in about 60% of
patients. Radiographs are generally not necessary.
Heel pain in this disorder is felt to be secondary to
repetitive microtrauma where the achilles tendon inserts
into the apophysis. Successful treatments have
included foam heel pads to elevate the heel and
reduce the stretch of the achilles tendon. Physical
therapy with gastocnemius-soleus stretching and
dorsiflexion strengthening has been useful as well.
Discontinuing aggravating activities is probably the
simplest treatment. Instructing patients to rest when
the pain worsens allows them to continue in their sports
without the need for orthopedic restrictions. For
persistent pain unresponsive to these therapies, short
leg walking casts have been used.
References
1. Meehan P. Heel Pain. In: Morrissy RT (ed).
Lovell and Winters Pediatric Orthopedics, 3rd edition.
Philadelphia, J.B. Lippincott Co., 1990, pp. 1001-1002.
2. Micheli LJ, Ireland ML. Prevention and
Management of Calcaneal Apophysitis in Children: An
Overuse Syndrome. Journal of Pediatric Orthopedics
1987;7:34-38.
3. Tolo VT, Wood B. Pediatric Orthopaedics in
Primary Care. Baltimore, Williams and Wilkins, 1993,
p. 229.
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