Sever's Disease

Sever’s Disease, also known as calcaneal apophysitis, is a common cause of heel pain in children and adolescents [Fares et al, 2021].
It is an overuse injury caused by repetitive microtrauma to the growth plate (apophysis) of the calcaneus (heel bone). This condition typically affects children between the ages of 8 and 15 years, coinciding with periods of rapid growth [Madden & Mellion, 1996; Duong et al, 2020; DiFiori et al, 2014].

The Achilles tendon RUN along the backside of the ankle connecting the calf muscle to the heel bone, and Sever's disease is due to the repetitive microtrauma to the growth plate due to the pull of the Achilles tendon during activities.
This repetitive stress leads to inflammation and pain at the site of the apophysis.
Factors such as rapid growth, tight or inflexible muscle-tendon units, and high levels of physical activity contribute to the development of Sever's disease [Madden & Mellion, 1996; Nieto-Gil et al, 2023; Becerro-de-Bengoa-Vallejo et al, 2014].
Additionally, intrinsic factors such as limited ankle dorsiflexion, foot malalignment, and high plantar pressures have been identified as contributing factors [Nieto-Gil et al, 2023; Becerro-de-Bengoa-Vallejo et al, 2014; Rodríguez-Sanz et al, 2018].

Clinically, Sever's disease presents with heel pain that is often exacerbated by physical activity, especially running and jumping.
Typically, symptoms are more gradual in onset and not associated with a specific injury [Madden & Mellion, 1996].

Diagnosis of Sever’s Disease is based on detailed history, physical examination, and imaging. Certain physical tests may be utilized to reproduce symptoms around the heel and measure range of motion of the foot and ankle at time of exam.
Radiographs (x-rays) evaluation are generally not required for the diagnosis of Sever's disease, as they typically appear normal. However, radiographs may be useful in ruling out other pathologies that could present with similar symptoms, such as bone cysts or stress fractures, which were identified in a small percentage of patients in their study [Rachel et al, 2011].

Conservative Management

Sever’s Disease is typically managed through conservative measures including rest, activity modification, ice, NSAIDs, and physical therapy.
Orthotic devices, including heel lifts, may also be utilized to relieve pain over the affected area [Madden & Mellion, 1996].
The condition usually resolves within a few weeks to months with appropriate management. In more severe cases, temporary immobilization may be required [Ogden et al, 2004].

References

DiFiori JP, Benjamin HJ, Brenner J, Gregory A, Jayanthi N, Landry GL, Luke A. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clin J Sport Med. 2014 Jan;24(1):3-20.
Duong MM, Nicholson AD, Li SQ, Gilmore A, Cooperman DR, Liu RW. Relationship Between Sever Disease and Skeletal Maturity. J Pediatr Orthop. 2020 Feb;40(2):93-96.
Fares MY, Salhab HA, Khachfe HH, Fares J, Haidar R, Musharrafieh U. Sever's Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clin Med Res. 2021 Sep;19(3):132-137.
Madden CC, Mellion MB. Sever's disease and other causes of heel pain in adolescents. Am Fam Physician. 1996 Nov 1;54(6):1995-2000.
Ogden JA, Ganey TM, Hill JD, Jaakkola JI. Sever's injury: a stress fracture of the immature calcaneal metaphysis. J Pediatr Orthop. 2004 Sep-Oct;24(5):488-92.
Rachel JN, Williams JB, Sawyer JR, Warner WC, Kelly DM. Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (sever disease)? J Pediatr Orthop. 2011 Jul-Aug;31(5):548-50.
Rodríguez-Sanz D, Becerro-de-Bengoa-Vallejo R, López-López D, Calvo-Lobo C, Martínez-Jiménez EM, Perez-Boal E, Losa-Iglesias ME, Palomo-López P. Slow velocity of the center of pressure and high heel pressures may increase the risk of Sever's disease: a case-control study. BMC Pediatr. 2018 Nov 19;18(1):357.

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