Sever?s disease

Related Terms

Achilles, ankle, apophysis, calcaneal apophysitis, dorsiflexion, foot, growth plate, growth spurt, gymnastics, gymnasts, heel lifts, heel pain, J. W. Sever, microavulsion, microtrauma, nonsteroidal anti-inflammatory drugs, NSAIDS, OsconT, Osgood-Schlatter's disease, overuse injury, physical therapy, repetitive exercise, RICE, self-limiting, Sever disease, Sever's disease, soccer, soccer players.

Background

Sever's disease is a disorder caused by overuse or injury of growth plates in the calcaneus (the heel bone), commonly a result of repetitive exercise. The disorder is also called calcaneal apophysitis, the painful inflammation (swelling) of the heel growth plate. It was named in 1912 by J. W. Sever, MD, when he first described it in the New York Medical Journal as an overuse syndrome that occurs when a particular body part is injured from overexertion or excessive strain.
Sever's disease is the most common cause of heel pain in older children, and it can occur in one or both heels. It has been compared to Osgood-Schlatter's disease, which is another overuse condition that affects the bones in the knees. Sever's disease predominantly affects athletic children (girls 8-10 years old, and boys 10-12 years old) entering early puberty. In persons less than 20 years of age, it has been estimated that it constitutes 5.8% of all injuries.
Soccer players and gymnasts are often affected, but any physical activity that involves running or jumping can cause Sever's disease. Although Sever's disease is painful, it generally only occurs during adolescent growth spurts and may last approximately six weeks to two months. Therefore, it is considered self-limiting, that is, it should resolve on its own. Children experiencing pain symptoms may limit exercise, rest, and use cold compresses, or in more severe cases, may use anti-inflammatory medications.

Signs and symptoms

Sever's disease typically causes pain or tenderness in the heel area, in one or both heels. It is frequently associated with decreased flexibility and dorsiflexion (the measure of how far one can bend back the foot) in the Achilles tendon. It may be characterized by nonradiating, often gradual pain in the posterior calcaneus (back of the heel), which may occur during physical or weight-bearing activity. Pain can range in degree and may even increase to levels that prevent further physical activity. Redness and swelling may also be visible.
Symptoms may arise at the beginning of a new sport or the start of a new season, or during a growth spurt, when the growth plates are still open. In the morning hours, symptoms may be worse, whereas during the night, symptoms may not be present. Children may have difficulty walking or appear to limp. Symptoms worsen with movement, but are self-limiting (they should resolve on their own) and typically decrease with rest.
Sever's disease has been shown to affect quality of life. Research has shown that children were less likely to be satisfied while experiencing symptoms, more likely to report pain, and less likely to be happy, compared to children not experiencing this condition.

Diagnosis

Sever's disease is commonly diagnosed using physical exams, a verbal history of symptoms, and X-ray findings indicating an absence of fractures. Physical exams may include a positive squeeze test for tight heel cords in which the physician squeezes the back of the heel to look for signs of pain. One diagnostic tool that uses images to examine internal structures and organs called ultrasonography has also been suggested as a means to examine the calcaneus during diagnosis; however, further research is needed. Dorsiflexion, or the backwards bending of the heel, less than 10 degrees may also be indicative of Sever's disease.

Complications

Although Sever's disease is painful, it generally only occurs during adolescence, and therefore is considered self-limiting. Currently, there are no known long-term complications or disabilities associated with Sever's disease. However, according to case reports, Sever's disease has delayed the diagnosis of more severe complications, or if neglected, has caused calcaneal apophyseal fractures. More research may be warranted in this area.
One report stated that an 11 year-old boy went to a practitioner following two years of pain and a diagnosis of Sever's disease following a nondescriptive radiograph, or an image produced by X-ray. Upon this second examination, which showed swelling and tenderness of the heel, and further radiographs, surgery was performed. During surgery, it was found that the proximal half of the calcaneal apophysis had been forcedly torn away and then displaced, and the resulting gap had since been replaced by fibrous tissue. After surgery and debridement (removal of dead tissue), the boy was able to resume his normal athletic activities.
In another case report, a 13 year-old boy who had been previously diagnosed with Sever's disease one year earlier was re-examined after experiencing severe pain and limping. After radiography, doctors found that the boy's upper calcaneal apophysis was displaced and had been moved upwards. Following reconstructive surgery and Achilles tendon repair, he was able to resume sports; however, his feet were reported to be seven millimeters different in length from one another.

Treatment

General: Sever's disease may affect children for weeks to months, and, rarely, years. Teens do not usually experience symptoms from Sever's disease after approximately age 15, because that is when the heel bone finishes growing and hardens. In general, children may go back to their regular activities when symptoms have ended.
There is currently a lack of high-quality clinical trials on specific treatment options for Sever's disease. The ultimate treatment goal is control of pain symptoms. Treatments typically vary in duration depending on the length of symptoms. Common treatments include modification of exercise, cool compresses, and rest. Decreased activity lessens swelling and associated pain. Anti-inflammatory medications such as ibuprofen or Advil ? may also be used in more severe cases.
Stretching or strengthening exercises: Specific exercises, such as heel lifts, may help stretch and strengthen muscles, tendons, the leg, and the heel. A physician may recommend exercises depending on symptom severity.
Modification of physical activity: If symptoms persist, modification of such exercises as running and jumping may help lessen pain.
Rest or cessation of sporting activities: If pain becomes too severe, children may have to stop playing sports until their symptoms decrease. Rest relieves the pressure put on the heel. It is considered by pediatric experts to be the ideal treatment, since physical activity can aggravate pain symptoms.
Ice or cool compresses: Ice or cool compresses are often used alone or in conjunction with NSAIDs (nonsteroidal anti-inflammatory drugs) to decrease swelling and pain symptoms. Icing placed on the heel 2-3 times daily is often recommended.
Physical therapy: Physical therapy may be used alone or in combination with other treatment options. A case report suggested that the use of a topical NSAID, ketoprofen, together with physical therapy improved a child's time to recovery and return to activities.
Orthoses: Shoe orthoses (devices used to correct body abnormalities or deformities) or padding for shock absorption may help alleviate heel pain. Heel lifts and arch supports may also help decrease pain symptoms. According to case reports, orthoses may decrease or eliminate the need for pain medication.
Nonsteroidal anti-inflammatory drugs (NSAIDs): Anti-inflammatory medications are often used in combination with rest, ice, compression, and elevation (abbreviated as RICE). A case report suggested that the use of ketoprofen, an NSAID that is applied to the skin, together with physical therapy, improved a child's time to recovery and return to activities.
Oscon?: Oscon?, an oral supplement, is marketed for use by children with Sever's disease and Osgood-Schlatter's disease, another overuse syndrome that affects the bones in the knees. Oscon? capsules contain organic selenium compounds (SelenoExcellT), Saccharomyces cerevisiae, and the natural form of vitamin E.
Iontophoresis: Iontophoresis or electromotive drug administration (EMDA) is a process that uses a small laser to give medicine through the skin without using a needle. This treatment has been described in case reports, but further scientific research is needed.
Crutches: Crutches may be used in severe cases, or if the pain is bilateral (in both heels).
Casts: Casts may be used in severe cases for 2-12 weeks to lessen pain symptoms.
Partial apophysectomy: Partial removal of the apophysis (bony outgrowth) of the calcaneus (the heel bone) may be performed in extreme circumstances.

Integrative therapies

Currently, there is a lack of scientific data on integrative therapies for the treatment or prevention of Sever's disease. However, according to case reports, a combination of vitamin E, vitamin C, and selenium (the contents of the product Oscon?) may help lessen symptoms. More research is needed in this area.

Prevention

Modification of physical activity: Sever's disease may be prevented or symptoms may be alleviated or lessened by using caution during physical activity that uses repetitive movements, such as running and jumping. Additionally, avoiding excessive running on hard surfaces may help.
Stretching or strengthening exercises: Specific exercises, such as heel lifts, may help stretch and strengthen muscles, tendons, the leg, and the heel.
Supportive footwear: High-quality shoes with specific features, including adequate arch support and shock absorbency, may help to prevent onset of symptoms.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep. 2010 Sep-Oct;9(5):265-8.
Hosg?ren B, K?ktener A, Dilmen G. Ultrasonography of the calcaneus in Sever's disease. Indian Pediatr. 2005 Aug;42(8):801-3.
James AM, Williams CM, Haines TP. Heel raises versus prefabricated orthoses in the treatment of posterior heel pain associated with calcaneal apophysitis (Sever's Disease): a randomised control trial. J Foot Ankle Res. 2010 Mar 2;3:3.
Lee KT, Young KW, Park YU, et al. Neglected Sever's disease as a cause of calcaneal apophyseal avulsion fracture: case report. Foot Ankle Int. 2010;31(8):725-8.
Madden CC, Mellion MB. Sever's disease and other causes of heel pain in adolescents. Am Fam Physician. 1996 Nov1;54(6):1995-2000.
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Causes

Sever's disease generally occurs during early adolescent growth. The inflammation, known as apophysitis, results from repeated minor traumas that cause tears at the bone-cartilage joint. In Sever's disease, the heel bone grows faster than the leg muscles and tendons, and the rate of tears is faster than the rate of bone healing. Repetitive physical activities including soccer, gymnastics, running, and jumping contribute to the pain symptoms. Sever's disease is thought to be linked to several factors, including rapid growth, resulting in increased tension to certain foot types (such as cavus or planus); infection; trauma; and obesity, although significant evidence is lacking in these areas.

Risk factors

Sever's disease primarily occurs during early puberty when heel growth occurs. It most commonly affects athletic children, but can occur in any child repeatedly using a running or jumping motion, for example, during sports such as basketball, soccer, and gymnastics. Girls aged 8-10 and boys aged 10-12 are most affected. According to case reports, the exact age of diagnosis varies. Boys are reportedly more affected than girls.
There is currently a lack of high-quality research identifying the exact cause of Sever's disease. Risk factors for Sever's disease may include the presence of pronated feet that roll inwards while walking, short-leg syndrome, flat feet, high arches, and obesity. Additionally, several factors may contribute to or worsen Sever's disease symptoms, such as poor-fitting shoes or standing for long periods of time.