What is sever’s disease? sever’s disease is a common cause of heel pain in active children. Sever’s disease, also called calcaneal apophysitis, occurs when the growth plate of the heel is injured by excessive forces during early adolescence.
The heel bone sometimes grows faster than the leg muscles (including the calf muscles) and tendons (including the Achilles tendon) during the early puberty growth spurt. The different growth rate in these structures can cause lower leg muscles and tendons to become overstretched and tight, which makes the heel less flexible and puts excessive pressure on the heel growth plate. The Achilles tendon, the strongest tendon in the body, attaches to the heel growth plate, and repetitive stress on this structure, especially if it?s already tight, can damage the growth plate, leading to tenderness, swelling, and pain. Activities that involve running or jumping, such as soccer, gymnastics, track, and basketball, can place significant stress on a tight Achilles tendon and contribute to the onset of Sever?s disease. Ill-fitting shoes can also contribute to this health problem by failing to provide the right kind of support or by rubbing against the back of heel. The following factors may increase the likelihood of Sever?s disease in kids or young teens. Wearing footwear that is too narrow in the toe box. Leg length inequality. Obesity or carrying excess bodyweight. Excessive foot and ankle pronation.
Typically, the sports injury occurs where the achilles tendon attaches to the bone. The epiphyseal growth plate is located at the end of a developing bone where cartilage turns into bone cells. As the growth center expands and unites, this area may become inflamed, causing severe pain when both sides of the heel are compressed. There is typically no swelling and no warmth, so it?s not always an easy condition to spot. The child usually has trouble walking, stiffness upon waking, and pain with activity that subsides during periods of rest.
Physical examination varies depending on the severity and length of involvement. Bilateral involvement is present in approximately 60% of cases. Most patients experience pain with deep palpation at the Achilles insertion and pain when performing active toe raises. Forced dorsiflexion of the ankle also proves uncomfortable and is relieved with passive equinus positioning. Swelling may be present but usually is mild. In long-standing cases, the child may have calcaneal enlargement.
Non Surgical Treatment
Treatment for Sever?s disease is mainly supportive, to stop inflammation and reduce pain. The condition will resolve on its own when the growth in the growth plate is complete, but until then, measures can be taken to resolve pain and discomfort. Applying ice to the painful or swollen areas on the foot may provide some short-term relief from pain and prevent further inflammation. Ice can be applied for about 20 minutes two or three times a day. Footwear that is too big, too small, or does not provide proper support can exacerbate the symptoms of Sever?s disease. Supportive footwear is important to prevent discomfort, especially in children who participate in sports and activities that take place on a hard surface (such as pavement or a basketball court). Shoes should also have adequate padding and not rub against the heel. In some cases, shoes that do not have heels (such as sandals) may be more comfortable to wear while the heel is healing, but care should be taken that the shoe provides proper support to the rest of the foot. Children with Sever?s disease should avoid going barefoot.Children with flat feet, high arches, or over-pronation may need treatment to resolve these underlying conditions. In many cases, an orthotic worn inside the shoe can help put the foot into a better alignment and provide relief to the foot or the arch. Children who are overweight or obese may be counseled to lose weight. Being overweight can contribute to the development of several conditions, including Sever?s disease. Resting the foot and discontinuing sports and other activities until the pain and stiffness is resolved may be recommended. In extreme cases, a walking boot or a cast might be used to completely immobilize the foot. A physical therapist may recommend stretching exercises for the muscles in the calf and the Achilles tendon. A stretching routine is usually done several times a day. Stretching these muscles can help improve strength and decrease the stress on the heel plate. Some physicians may recommend over-the-counter pain relievers such as ibuprofen or acetaminophen. Care must be taken when administering these medications to children, especially with acetaminophen, as overdoses are possible when using more than one medication containing acetaminophen. Aspirin should never be given to children. The utility of pain relievers in children must be weighed against their possible side effects. For small variations-less than an inch or so-shoe lifts can help equalize the length of the legs. In cases with more variation between legs, surgical solutions may be considered. Research indicates that targeted manual therapy techniques performed by a licensed physical therapist can help to reduce pain from Sever?s Disease and to improve muscle function. When the larger calf muscles and the smaller ankle and foot muscles become tight, this tightness can affect the mechanics of the ankle joint. Manual therapy includes both joint and muscle release techniques to restore optimal function to the calf, ankle, and foot muscles, and results can generally be achieved within a few months.
The following exercises are commonly prescribed to patients with Severs disease. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 1 – 3 times daily and only provided they do not cause or increase symptoms. Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms. Calf Stretch with Towel. Begin this stretch in long sitting with your leg to be stretched in front of you. Your knee and back should be straight and a towel or rigid band placed around your foot as demonstrated. Using your foot, ankle and the towel, bring your toes towards your head as far as you can go without pain and provided you feel no more than a mild to moderate stretch in the back of your calf, Achilles tendon or leg. Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free. Calf Stretch with Towel. Begin this exercise with a resistance band around your foot and your foot and ankle held up towards your head. Slowly move your foot and ankle down against the resistance band as far as possible and comfortable without pain, tightening your calf muscle. Very slowly return back to the starting position. Repeat 10 – 20 times provided the exercise is pain free. Once you can perform 20 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms. Bridging. Begin this exercise lying on your back in the position demonstrated. Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for 2 seconds then slowly lower your bottom back down. Repeat 10 times provided the exercise is pain free.