Synonyms: calcaneal apophysitis.

Sever's disease is a term used to describe inflammation of the calcaneal apophysis which occurs in children and adolescents.

Sever first described the condition in 1912.¹ Further studies have suggested that the condition is due to repeated "microtrauma" at the site of the attachment of the Achilles tendon to the apophysis of the heel, frequently occurring as a result of sporting activities.²

In a study of 85 children with 137 affected heels, it was bilateral in 61%.³ The condition is similar in nature to Osgood-Schlatter's disease of the knee, and in a survey by the Football Association, these 2 conditions were found to account for over 13% of all injuries to young footballers between the ages of 11 and 13.⁴

Epidemiology

It is seen most commonly in boys between the ages of 10 and 13 - the time at which the calcaneal apophysis begins to ossify. It tends to occur slightly earlier in girls. It is this line of ossification which is thought to develop microfractures as a result of recurrent stresses on the heel combined with the growth spurt of puberty. The condition is more common in young people active in sport, and boys are more frequently affected than girls.⁵

Presentation

Sever's disease must be considered as a possible diagnosis in young physically active individuals who present with :

• Heel pain
• Gradual onset
• Worse on exercise
• Relieved by rest
• May be bilateral (61%)
• Tenderness on palpation of the heel
• Pain on dorsiflexion of the ankle
• ± swelling of the heel
• ± calcaneal enlargement

Differential diagnosis

• Achilles tendonitis
• Stress fractures
• Osteomyelitis
• Tarsal coalition

History

Ask specifically about:

• The nature of the pain
• Aggravating or relieving factors
• History of trauma
• Activities - sport, ballet, gymnastics etc.
  • How often do you train?
  • How often do you compete?
  • At what level?
• Type of shoes normally worn
• Any other medical conditions or medications

Examination

• Shape of heel
• Swelling around heel
• Localised tenderness
• Pain on forced dorsiflexion

Investigations

Investigation should not be required routinely. Investigation to look for other causes is suggested if:

• Pain is persistent or significant at rest
• Pain disturbs sleep
• There is significant swelling
• If there is reduction of subtalar movement (suggests tarsal coalition)

• X-ray of heel may show increased sclerosis and fragmentation of the calcaneal apophysis but these features are nonspecific and it may be normal. The value of X-ray is to exclude fracture or a rare tumour. The diagnosis is clinical, not radiological.⁶
• CT or MRI scan may be useful to exclude osteomyelitis or fusion of the small bones of the hindfoot. It is not always required.

Management

Non-drug

• The basis of treatment is to reduce repetitive trauma from such activities as football, running and jumping.
• The heel may be further protected by the use of in-shoe heel lift or heel cup, worn at all times.
• The application of ice, both at times when the heel is painful and also when it is relatively pain free, will reduce the inflammation.
• Physiotherapy may be useful to massage the affected muscles and develop a programme of stretching exercises.
• Severe cases may benefit from a 2-3 week treatment with a cast in mild equinus followed by a brief period using crutches.

This needs to be managed along the normal lines for sports injuries. Simply telling an individual to give up his chosen sport is not satisfactory. This may be a very talented young footballer who hopes to earn a very lucrative living from the sport. Explain to the child and parent that this is an overuse injury, common in the growing child. It has a good prognosis but it is necessary to ease back on training for a while to let it recover. Offer to talk to the coach. If the parent and coach are one and the same, beware that the child is being "pushed" too hard.

During abstinence from normal training, cardiovascular fitness can be maintained by non-weight bearing exercise such as swimming or cycling.

Drugs

An anti-inflammatory agent such as ibuprofen will reduce pain but it is not a substitute for rest from sporting activities.

Prognosis

The condition is normally self-limiting, and a return to normal activities is usually possible after a period of 2-3 months.⁷ There is usually swift recovery but recurrence is common.³