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Posterior Calcaneus Apophysitis
From WikiSM
Other Names
- Sever's Disease
Background
- This page refers to apophysitis of the calcaneus, a pediatric condition often called 'Sever's Disease'
History
Epidemiology
- Most common cause of heel pain in active adolescents between 9 and 12 years of age (need citation)
Pathophysiology
- General
- Seen in skeletally immature athletes
- Traction at the Achilles Tendon insertion site correcting with the secondary ossification center
- Occurs with growth spurts, increased activity, or repetitive running and jumping
- Presents as heel pain secondary to overuse
- Resolves with skeletal maturation and closure of apophysis
Etiology
- Repetitive strain and microtrauma
- Caused by force of the Achilles tendon which inserts at secondary ossification center
- Results in irritation and potential partial avulsion of the calcaneal apophysis
Risk Factors
- Sports
- Running and jumping sports
- Basketball
- Soccer
- Gymnastics
- Extrinsic
- Long or year-round activities
- Poorly fitting or worn-out footwear
- Poor training mechanics
- Intrinsic
- Poor heel cord flexibility
- pes cavus
- pes planus
- genu varum
- forefoot varus
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
Clinical Features
- History
- Children are typically 8 to 14 years old
- Pain over the calcaneal apophysis/calcaneal insertion of Achilles tendon
- Pain with activity or impact, worse on hard surfaces, wearing cleats
- Resolution of pain with rest
- Limping may be present
- Physical Exam: Physical Exam Ankle
- May have erythema, swelling, warmth
- Tender over achilles tendon insertion
- Pain with passive ankle dorsiflexion
- Tight Achilles tendon and calf muscles
- Pes planus or pronated forefoot may be present
- Special Tests
- Squeeze Test: Pain over the posterior calcaneus with compression)
- Sever Sign: Increased pain at calcaneus with standing on tiptoes
Evaluation
- Clinical diagnosis and imaging is not routinely required
Radiographs
- Standard Radiographs Ankle or Standard Radiographs Foot
- Typically normal, especially early in disease process
- Rule out other pathology including fractures, osteomyelitis, bone cysts
- Potential findings
- Sclerosis may be present
- Fragmentation is frequently present
MRI
- Findings
- Localize inflammation to apophysis
- Evaluate for other pathologies stress fracture, lytic lesions, osteomyelitis
Classification
- N/A
Management
- Indications
- All patients
- Activity modification/Rest
- Discontinue offending activity
- Physical Therapy
- Achilles tendon stretches, hamstring stretches
- Strengthening of dorsiflexors
- Heel pads/cups
- Insertion can offload some tenson on achilles
- Immobilization in severe cases
- Either Tall Walking Boot or Tall Walking Cast
- May require non weight bearing status
- Other
- Ice
- NSAIDS
- Establish proper footwear
- Prevention
- Maintain calf flexibility and ankle dorsiflexion
- Limit use of cleats or time on hard surfaces
Operative
- Indications
- No role for operative treatment
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Needs to be updated
Complications & Prognosis
Prognosis
- General
- Self-limited usual improvement within 6 to 12 months
- Symptoms can wax and wane for athlete
- Complete resolution with apophyseal closure
Complications
- None
See Also
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
Created by:
John Kiel on 30 June 2019 20:36:32
Authors:
Last edited:
3 October 2022 23:52:47
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