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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:
16 January 2023 19:32:26

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