A 9-year-old boy presents with a 2-month history of right heel pain that has worsened over the previous 2 weeks. He is an avid soccer player who plays at least 2 hours every day, 6 to 7 days each week. His parents state that he is a very talented player who is on a number of all-star teams throughout the year. On examination, the child’s heel is tender over the calcaneal apophysis, and tenderness is made worse with active plantar flexion and passive dorsiflexion. An x-ray is taken.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
Submit your diagnosis to see full explanation.
Based on the patient’s history of playing soccer every day without regular days of rest, an overuse injury should be suspected. Calcaneal apophysitis, or Sever disease, is a common source of activity-related heel pain in skeletally immature athletes.1
During running, the calcaneal apophysis experiences strong pulling forces from both the Achilles tendon and the plantar fascia. These repetitive forces can cause a traction apophysitis and heel pain, particularly in athletes who do not stretch adequately or rest enough.
Most patients have pain to palpation over the apophysis on examination and a history of progressive activity-related heel pain. A lateral x-ray can help differentiate Sever disease from other sources of heel pain, including bone tumors or stress fracture. Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle.2 Sinding-Larsen-Johansson syndrome is a traction apophysitis of the distal pole of the patella.2 Iselin disease is a traction apophysitis at the base of the fifth metatarsal.2
Treatment involves activity modification, immobilization, physical therapy for Achilles tendon stretching, local modalities, nonsteroidal anti-inflammatory drugs, and heel cups.1 Casting may be necessary in noncompliant patients or if other treatments fail. Recurrence is common until patients reach skeletal maturity.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Souder C. Sever’s disease. Orthobullets. http://www.orthobullets.com/pediatrics/4074/severs-disease. Accessed January 4, 2016.
- Frank JB, Jarit GJ, Bravman JT, Rosen JE. Lower extremity injuries in the skeletally immature athlete. J Am Acad Orthop Surg. 2007;15(6):356-366.