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Figure. Lateral radiograph of the right foot.
A 12-year-old boy presents with right heel pain that has been present for the past 6 weeks. He noticed the pain when he started soccer practice and the pain has become progressively worse since. The patient reports having trouble running due to the pain. On physical examination, he has no obvious deformity to the foot or ankle. He has tenderness to palpation over the posterior calcaneus and mild pain with resisted plantar flexion. Lateral radiograph of the right foot is taken (Figure).
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Severs disease, or calcaneal apophysitis, is a common condition seen in pediatric and orthopedic clinics. The typical presentation is in children aged 8 to 15 years who present with heel pain after starting an athletic activity.1 These patients often start the sports activity with minimal to no pain but will soon limp off the field or court in pain.
The etiology of Severs disease is unknown although the widely accepted theory is that the condition occurs during a growth spurt when the long bones grow faster in length than the tendons. Subsequently, the Achilles tendon becomes tight creating a traction apophysitis to the calcaneal apophysis. As the foot grows in length, the plantar fascia increases in tension at its insertion site on the calcaneus, which can contribute to the pain.1,2
The diagnosis of Severs disease is made clinically by pain with palpation over the posterior heel (calcaneal apophysis) and open growth plates seen on radiographs. Radiographs are typically normal but may show fragmentation at the apophysis.1-3
Treatment involves activity modification, nonsteroidal anti-inflammatory drugs, and if symptoms warrant, a period of immobilization. Padded heel cups, orthotics with arch support, and heel lifts have been used without definitive evidence showing significant efficacy.1,3 Once the child is fully grown, Severs disease will not return.2
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 Orthopaedics for Physician Assistants.
References
1. James AM, Williams CM, Haines TP. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review. J Foot Ankle Res. 2013;6(1):16. doi:10.1186/1757-1146-6-16.
2. American Academy of Orthopaedic Surgeons. Sever’s disease. OrthoInfo. Accessed 10/18/2021. https://orthoinfo.aaos.org/en/diseases–conditions/severs-disease/
3. Scharfbillig RW, Jones S, Scutter SD. Sever’s disease: what does the literature really tell us? J Am Podiatr Med Assoc. 2008;98(3):212-223. doi:10.7547/0980212.
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