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Calcaneal Apophysitis

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Other Names

  • Sever's Disease
  • Traction Apophysitis Injury of the Ankle
  • Calcaneal Apophyseal Avulsion Fracture

Background

  • This page covers apophysitis of the calcaneus, a cause of heel pain seen in kids often referred to as Sever's Disease

History

  • First reported in 1912 by James Warren Severe, an orthopedic specialist[1]
  • In 1926, Lewin first postulated a cause[2]

Epidemiology

  • The most common cause of heel pain in pediatrics
    • Primarily seen between the ages of 8 and 15
    • Median age: males (12 years), females (11 years) (need citation)
    • Has been observed in children as young as 6[3]
  • Reported incidence of 3.7 per 1,000 patients[4]
  • Up to 60% of cases are bilateral (need citation)
  • Reported to account for between 2% and 16% of heel pain in children presenting to sports clinics[5]

Pathophysiology

Calcaneal apophysis is located posterior to calcaneus. Calcaneal apophysis is the insertion site of the Achilles tendon[6]
  • See: Apophyseal And Epiphyseal Injuries (Main)
  • General
    • Self limiting condition which occurs due to repetitive stress at the calcaneal apophysis
    • Often seen following a growth spurt in conjunction with increased sport participation
    • The diagnosis is primarily clinical

Etiology

  • Repetitive microtrauma
    • Movement of the apophysis relative to the diaphysis causes trauma to the apophyseal tissues with compression or impact forces
    • Approximately 60% of the weight-bearing load occurs in the rear foot when standing
    • Sports with running and jumping report more pain (need citation)
  • Growth
    • Apophysis is the weakest point in the muscle-tendon-bone-attachment
    • Bone growth exceeds the ability of the muscle-tendon unit to stretch sufficiently to maintain previous flexibility
    • This leads to increased tension across the unossified or incompletely ossified apophysis
  • Avulsion fracture
    • Rarely, trauma may lead to a full avulsion fracture

Pathoanatomy

  • Calcaneus
    • Apophysis is the posterior aspect of the calcaneus, where the Achilles tendon inserts.
    • Growth plate does not close until at least 14 years of age.

Risk Factors

  • Systemic
  • Sports
    • Soccer
    • Track and Field
    • Basketball
    • Cross-country
    • Gymnastics
  • Training/ Conditioning
    • High levels of physical activity
    • Heel cord tightness
    • Weak ankle dorsiflexion
    • Poorly cushioned or worn-out athletic shoes
    • Running on hard surfaces
  • Biomechanical[8]
    • Genu varum
    • Forefoot varus
    • Pes cavus
    • Pes planus

Differential Diagnosis

Differential Diagnosis Ankle Pain

Differential Diagnosis Foot Pain


Clinical Features

The calcaneal squeeze test[9]
  • History
    • Age is typically 8 to 15
    • No specific injury
    • Complain of heel pain, especially after athletic activities
    • In severe cases, pain may occur at rest
    • Patient may point more towards Achilles than to calcaneus
    • May report a limp walking on toes
    • Trouble running, jumping
    • Pain is often bilateral
  • Physical Exam: Physical Exam Foot
    • Erythema, edema are typically absent
    • Tenderness with palpation or compression of medial and lateral heel
    • Dorsiflexion is often limited an dpainful
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Alternatively can be seen on Standard Radiographs Ankle
    • May appear normal, not always diagnostic
    • The diagnosis is primarily clinical, imaging is not required to confirm diagnosis
  • Findings
    • Increased density
    • Fragmentation of the calcaneal apophysis

Classification

  • Not applicable

Management

Kinesio taping treatment applied to the Achilles tendon and heel region[10]

Nonoperative

  • Indications
    • First line in all cases
  • Treatment Guidelines
    • There are no clear, evidence based treatment guidelines
    • Further evaluation of treatment methods is needed[11]
  • Activity modification
    • Must discontinue sport or offending recreational activity
  • Ice therapy
  • NSAIDS
  • Physical Therapy
    • Stretching of posterior chain and especially calf muscle and achilles tendon
  • Immobilization
  • Kinesiology Taping
    • Tape around the arch, heel may reduce pain
  • Heel Cups
    • Help absorb impact during running, jumping
    • Decrease microtrauma during normal activities of daily living
    • Perhamre et al found heel cups reduced pain to nearly 0/10 after about 4 weeks[12]

Operative

  • Indications
    • Calcaneal apophyseal avulsion fracture

Rehab and Return to Play

Rehabilitation

  • Emphasis on stretching posterior chain, especially calf muscles

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Self limited condition

Complications

  • Reoccurrence of pain
  • Calcaneal apophyseal avulsion fracture
    • Few case reports in the literature[13]

See Also


References

  1. Sever JW: Apophysitis of the os calcis. NY Med J. 1912, 95: 1025-
  2. Lewin P: Apophysitis of the os calcis. Surg Gynecol Obstet. 1926, 41: 578-
  3. Volpon J, de Carvalho Filho G: Calcaneal apophysitis: a quantitative radiographic evaluation of the secondary ossification center. Arch Orthop Trauma Surg. 2002, 122: 338-341.
  4. Wiegerinck, J. I., Yntema, C., Brouwer, H. J., & Struijs, P. A. (2014). Incidence of calcaneal apophysitis in the general population. European Journal of Pediatrics, 173(5), 677–679.
  5. Micheli LJ, Fehlandt AF: Overuse injuries to tendons and apophyses in children and adolescents. Clin Sport Med. 1992, 11: 713-726.
  6. H.Chang, S.-S.Kwon, and K.-W.Minn, “Lateral calcaneal artery as a recipient pedicle for microsurgical foot reconstruction,” J. Plast. Reconstr. aesthetic Surg., vol. 63, pp. 1860–1864, 2010.
  7. James, A. M., Williams, C. M., Luscombe, M., Hunter, R., & Haines, T. P. (2015). Factors associated with pain severity in children with calcaneal apophysitis (Sever’s disease). The Journal of Pediatrics, 167(2), 455–459.
  8. McSweeney SC, Reed L, Wearing S. Foot Mobility Magnitude and Stiffness in Children With and Without Calcaneal Apophysitis. Foot Ankle Int. 2018 May;39(5):585-590.
  9. B. Hosgoren, A. Koktener, and G. Dilmen, “Ultrasonography of the calcaneus in Sever’s disease,” Indian Pediatr., vol. 42, p. 801, 2005.
  10. M.P.McHugh and C.H.Cosgrave, “To stretch or not to stretch: the role of stretching in injury prevention and performance,” Scand. J. Med. Sci. Sports, vol. 20, pp. 169–181, 2010.
  11. Leeb H, Stickel E: Literature review of sever’s disease: radiographic diagnosis and treatment. Podiatric Medical Review. 2012, 20: 4-9.
  12. Perhamre, S., et al. "A heel cup improves the function of the heel pad in Sever's injury: effects on heel pad thickness, peak pressure and pain." Scandinavian journal of medicine & science in sports 22.4 (2012): 516-522.
  13. Lee KT, Young KW, Park YU, Park SY, Kim KC: Neglected sever’s disease as a cause of calcaneal apophyseal avulsion fracture: case report. Foot Ankle Int. 2010, 31: 725-728. 10.3113/FAI.2010.0725.
Created by:
John Kiel on 9 March 2022 16:09:10
Authors:
Last edited:
4 October 2022 12:45:09