Also know as Calcaneal Apophysistis, Sever’s disease is a condition in which the heel bone and growth plate is irritated where the Achilles tendon attaches the calf to the heel bone. This most commonly occurs in children in and around growth spurts. It causes pain in the heel and may limit walking and participating in high impact sports.
The cause of this inflammatory condition is associated with periods of significant growth resulting in the muscle and tendon tissue being tight and creating tension at their attachment point to the bone. These growth changes in conjunction with increased volume or intensity of running, cutting, and training will lead to this painful condition. Poor foot biomechanics and poor proximal core and hip motor control can also contribute to this condition. These growth changes in conjunction with poor mechanics and increased volume or intensity of running, cutting and training can lead to this painful condition.
Sever’s Disease can be caused by a number of things but can most often occur after a growth spurt when tissues, bones, cartilage, tendons, and muscles grow rapidly. Injury can be more likely during this time due to the fact that the soft tissue and bones shift during the growing process. High impact sports put stress on the achilles tendon. Repeated stress on the achilles tendon causes swelling and pressure on the growth plate resulting in heel pain.
Boys are slightly more at risk than girls and most commonly occurs in children age 8 to 14. Risk factors include participation in high impact sports such as volleyball, basketball, gymnastics or frequent running and jumping, especially on hard surfaces. Children who are overweight or obese are at higher risk as well as those who wear poor or inappropriate foot wear for the activity they are performing.
The symptoms of Sever’s disease consist of a gradual onset of heel pain where the Achilles tendon inserts into the bone, occasionally associated with localized swelling. This is associated with local tenderness to palpation over the heel bone. It is quite often found on both sides. It is commonly found in adolescents ages 10-15 and often related to participation in sports involving running, cutting and jumping.
Your child may experience pain, swelling, and noted redness around the back of one or, most commonly, both heels. You may note that your child walks on the toes, avoiding heel contact, or walks with a limp. Pain and tenderness tends to worsen with the aggrevating activities mentioned above and improve with rest.
Physical examination and movement testing are performed to assess strength, reflexes, and reproduction of symptoms with movement. Palpation, putting slight pressure around your child’s heel and foot, will help your physical therapist determine the exact source of the pain. This testing can be performed by a Results Physiotherapist. If this testing is unlcear or does not present with expected outcomes with initial treatment by your physiotherapist (PT), further testing may be required. This can include X-ray or MRI and may include referral to an Orthopedist.
Depending on severity of condition and/or lack of response to conservative treatment (i.e. Physical Therapy), occassionally your child may be instructed to wear an ankle boot to allow for the aggrevated tissues to rest and heal. After diagnosis by your child’s PT or other health care provider (PCP, pediatrician, orthopedist, etc) you will be instructed in treatment options and need for further assessment as stated above.
Physical therapy can help with the pain and inflammation associated with Sever’s disease by improving mechanics around the achilles insertion point on the heel and strengthening areas of weakness or muscle imbalance and stretching the tissues to prevent further aggrevation from occuring. At Results Physiotherapy a highly skilled PT will perform a thorough examination to establish an individualized treatment plan specific to your child’s impairments and functional needs.
This will include hands on manual therapy to your child’s calf muscles and tendons and ankle or foot joints to reduce stress to the growth plate in the heel. Once the growth plate inflammation is reduced, your child will begin exercises to strengthen the muscles in the calf, hip and core that may be weak due to the rapid growth spurt. Finally your child will be trained how to perform sport specific activities with good ergonomics to safely return to their sport.
Footwear and orthotics (if needed) will be recommended during treatment by your PT as well. Triggerpoint Dry Needling is an adjunct tool to hands on manual therapy treatment for Sever’s disease. If appropriate for your child, your PT may recommend this course of treatment to get your child better faster. In the case of Sever’s disease the solid filament needle may be placed in the calf muscles to directly release pressure placed on the Achilles Tendon. This allows the stress and pull on the point of attachement of the heel and growth plate to be reduced allowing for healing.
Upon discharge from Physical Therapy, your child will have instructions to continue a maintenance home exercise program to prevent the condition from occuring again as well as when to contact your PT if symptoms recur or do not continue to improve as expected. Sever’s disease is not a life long condition and tends to resolve once the growth plates have hardened fully. PT can help until this state of development occurs in your child.
Relative rest and activity modification, followed by a gradual return to sporting activity is usually indicated. Occasionally a 1-2 week bout of immobilization is indicated in severe cases. Regular use of ice post activity assists in controlling inflammation as return to full activity is ramped up. Calf flexibility exercises and deep tissue mobilization is important to relieve muscle tightness. Motor control exercises and shoe inserts/orthotics are both very useful in correcting poor mechanics.
Warm ups and cool downs are very important for your child’s developing tissues. Getting a good warm up in before participating in high impact sports can prepare the muscles and tendons for the demand put on the Achilles in jumping and running sports. Stretching the Achilles, hamstrings and calf muscles should occur after activity as well as this is when your child’s tissues are warm and safe to perform long hold stretches needed for the rapid growth spurts.
Maintain a healthy weight. For every pound over your child’s healthy weight it puts an added 5 pounds of pressure on their joints. Make sure your child is wearing the appropriate footwear for the sport they are performing. If shoes are old and worn out or ill fitting, this can contribute to Sever’s Disease as well.
Don’t ignore your child’s heel pain or write it off as “growing pains”. Early intervention is the best prevention. You may be able to reduce the number of PT visits your child needs as treatment at the onset of a condition is less involved than when it becomes subacute (greater than 6 weeks) or chronic (greater than 3 months). With subaccute and chronic conditions maladaptive movement patterns occur. While still treatable with Physical Therapy, it requires longer treatment to address, not only the primary dysfunction at the heel, but the maladaptive movement patterns that can occur in the foot, knee, hip and spine as a result of moving in a way, such as limping, to reduce or avoid pain.