What is Severs disease?
Severs disease is a traction apophysitis (inflammation of the growth area) of the calcaneal (heel bone). It is a common cause of heel pain in young athletes. This causes pain and swelling.
What causes Severs disease?
Severs disease is caused by repetitive excessive force to the growing area of the heel bone, causing injury to this area.
The calf muscles (soleus and gastrocnemius) are attached by the Achilles tendon to the calcaneus (heel bone). They exert a huge force during running , jumping and landing. In children, there is a growing area in the heel bone called the apophysis and is made of relatively weak cartilage.
If there is excessive force at this relatively weak point damage occurs. This excess force can be caused by a number of factors.
During the adolescent growth spurt the bones grow very quickly. The muscles do not grow out at the same rate as the bone grows and so can become very tight. The calf muscles generate huge forces when they are used to run, jump and land. This force is transmitted to the calcaneal apophysis (growth area). The gastrocnemius muscle spans both the ankle and knee joint. Tightness of this or any other muscles of the lower limb (hamstring or quadriceps) cause extra force at the growing (weak) area. In active children, who undertake a lot of exercise, the repetitive high force causes damage.
If your child has poor biomechanics due to poor lower limb alignment (often caused by flat feet), the muscles of the lower limb have to work excessively hard and this can cause increased force at the tibial tubercle.
Symptoms of Severs disease
Severs causes swelling, pain and tenderness over the back of the heel. Your child may walk with a limp.
Initially the pain may be intermittent occurring only during or after exercise. As the problem gets worse, pain may be present most of the time. The swelling increases and is painful when touched or knocked.
It commonly affects boys who are having a growth spurt during their pre-teen or teenage years. One or both knees may be affected.
How is Severs disease diagnosed?
All medical diagnosis should be made by taking a full history, examining the patient then performing investigations.
The problem usually occurs in boys who are going through or have just gone through a growth spurt; one or both heels may be affected.
Initially the pain may be intermittent occurring only during or after exercise. As the problem gets worse, pain may be present most of the time.
There may be swelling over the back of the heel and this area is painful if touched or knocked.
On examination the patient often has flat feet, very tight legs muscles especially the gastrocnemius.
Xrays may show some increased density of the calcaneal apophysis (black arrow).
An MRI scan will show features of inflammation (whiteness) in the calcaneal apophysis.
Xray and MRI scans are also used to rule out other causes of pain.
How is Severs disease treated?
The initial treatment is rest, relieve the pain and treat the underlying cause.
The foot and ankle should be rested so that the apophysis it is not being continually “injured”. A small heel (sorbothane heel insert) raise can used to raise the heel and take the stretch off the Achilles tendon.
It may be sufficient to stop your child playing sport but some children require a short period of bed or couch rest. Some children find resting very difficult and require the use of braces or plasters or boots to slow them down. Using crutches is advised.
Severs is usually caused by tight muscles. A stretching program should be followed usually supervised by a physiotherapist. The stretching program may need to be undertaken up to 5 times a day.
If flat feet are a problems orthotics (insoles) should be used.
The pain should be controlled by rest (limiting activity) and ice (icing the painful area 3-4 times a day – making sure the skin is not burnt), Simple pain killers can be used such as paracetamol as well as anti-inflammatory tablets and cream.
Severs disease usually goes away with time. When your child stops growing, the pain and swelling should go away because the growing (weak) area fuses and becomes solid bone which is very strong.
How long will it take for my child’s heel to get better?
It may take several weeks or months for the pain to completely stop. When the pain is completely gone, your child may slowly return to his or her previous level of activity.
What can my child do to help prevent Severs disease from developing or happening again?
It is important to undertake correct warm ups and warm downs before and after exercise. This should include a stretching routine.
It may be necessary to undertake additional stretching outside of sport, especially during stages of growth.
Only playing one sport should be avoided.
You should not allow your child to play through pain.