As summer comes to a close and the fall sports season begins, many kids will begin or resume participation on organized sports teams and in school PE class. This means an increase in growing kids experiencing heel pain, a very common condition known as Sever’s Disease or Sever’s Injury. The anatomical term is Calcaneal Apophysitis, which is heel pain at the insertion of the Achilles tendon on the calcaneus. The pain is caused by the constant pull of the Achilles tendon on the unossified apophysis, causing inflammation. This is typically a benign condition that kids experience between the ages of 8 & 15, onset is usually earlier for girls than boys. Kids that participate in high impact, change of direction and jumping sports, such as soccer and basketball tend to be more at risk. A recent growth spurt may also accompany the onset of pain because as kids grow, their bones elongate prior to the muscles which increases the muscles passive tension. The tension is transfered to the tendon’s bony attachment, in this case the calcaneus. Adults will be more likely to experience Achilles tendinitis or plantar fasciitis, but in children the unossified calcaneal apophysis is the weak point and becomes irritated.
Physical signs are painful responses to direct palpation and pain with active or passive ankle plantarflexion & dorsiflexion. Visually, there is rarely swelling or discoloration but the athlete may adopt an abnormal walking gait such as toe walking or walking with the foot outwardly rotated. Symptoms are aggravated by high levels of activity, sports participation and stairs.
A visit to the Pediatrician or Orthopedist will not usually include an x-ray, often subjective comments and physical examination are enough for the MD to make a diagnosis. Common treatment options are rest, activity modification, ice and light stretching. Many Doctors in the area prescribe Physical Therapy not only to address the pain at the heel, but also to work on full body flexibility and to correct inefficient movement patterns that may overload certain muscles and tendons.
Evidence Based Advice for Treatment
Most of the kids I see are not interested in taking a few weeks off from sports participation. They are OK with doing the home stretches and coming into the clinic a few times per week, but complete rest is not an option. For these kids and parents I recommend wearing a heel cup shoe insert along with daily stretching and attendance in Physical Therapy. I give this advice based off clinical experience as well as support from a series of studies by Perhamre et al. published in the Scandinavian Journal of Medicine & Science in Sports.(1,2,3) The research group found that shoe inserts without reduction in sports activity helped kids get through the painful phase associated with Calcaneal Apophysitis. They studied several types of inserts and found heel cups to be most effective and that they were preferred by participants who were given a choice.
The idea of adding something to the heel of an already shortened Achilles and Calf seems counter intuitive but since this is a temporary phase of growth and stretching is being prescribed, I have yet to see the Achilles/Calf get shorter or condition worsen from this treatment.
I absolutely recommend that if pain gets worse, becomes constant, leads to severe limping or if the child is unable to tolerate basic daily activities despite the stretching regimen that they stop all activities and follow up with the MD.
Home Stretching Program
Its important to stretch the entire lower extremity to prevent other apophyseal irritation such as Osgood Sclatters. Stretches should be performed several times per day, hold each position 20-30 seconds for 3 sets, no bouncing.