WHAT IS SEVERS DISEASE
Severs disease is a common growth plate problem affecting children of all backgrounds. It is also known as calcaneal apophysitis, which means inflammation of the growth plate in the back of your heel bone. Sever’s is common in children between the age of 7 and 14 years and can commonly occur during a growth spurt, when children grow quickly over a short time frame. As sports podiatrists, we often see children who are physically active, who complain of pain around the back of one or both heel bones. Their calf muscles are often tight and they may be involved in a minimum of 3 to 4 periods per week, of sport / physical activity. They may report pain that is present each morning when rising from bed, and an increase in symptoms from quick movement sports or activities that involve jumping.
MORE ABOUT SEVER’S DISEASE
Sever’s disease can be described as an out of synch growth pattern, whereby the calf bones grow quicker than the calf muscles / Achilles tendon.
During this growth spurt, your heel bone also grows more quickly than the calf muscles. As these bones grow faster than your muscles, your Achilles tendon that attaches the calf muscles to the back of the heel pulls hard on the heel bone, as it essentially becomes too short. The net result is an increased pull on your growth plate at the back of the heel. The growth plate of this heel bone (calcaneus) is cartilage that hast not ossified yet (developed into mature bone) and hence is a weak target for this increased pulling sensation. What ensues can be described as a traction injury which can be seen in association with inflammation and posterior / plantar heel pain. Severs disease can render your child inactive as they pull out of sporting activities.
SYMPTOMS OF SEVER’S DISEASE
- Pain and stabbing around the back of the heel (calcaneus)
- Swelling / inflammation at the posterior heel (sometimes redness too)
- Ambulation – or walking with a pronounced limp
- Unable to load the heel when walking
- Walking on tip toes of affected foot
- Morning symptoms – heel pain and stiffness
OTHER CONTRIBUTING FACTORS
- Stiff or tight calf muscles with a restricted range of ankle joint motion
- Frequent / excessive sessions of sport or physical activity
- Quick movement sports such as football / basketball / sprinting / jumping / running
- Softer shoes / fatigued footwear – less supportive
- Biomechanical issues such as over pronation or pes cavus foot type (high arches)
- Children who are carrying too much body weight
DIAGNOSIS OF SEVERS
As sports podiatrists, we can conduct a thorough physical examination, and this is sufficient. We can rule out other causes of heel pain such as plantar fasciitis and Achilles Tendonitis by applying gentle pressure to different parts of the heel bone. We can assess the range of motion in your child’s ankle joint, based on the flexibility, or lack of, in their calf. We check to see if there is a leg length discrepancy, as this can cause a bio mechanical imbalance, which affects the pressure and load on each of the feet.
We use digital software to assess and record foot function as your child walks (and runs if necessary) on a treadmill. Replaying this footage in slow motion allows us to detect any bio mechanical anomalies which can be addressed accordingly. There are usually some key bio mechanical issues that can be detected in children who are presenting to the sports podiatrist, complaining of severs disease symptoms. At Sydney Heel Pain Clinic we find an equal number of boys and girls complaining of Severs disease and there is no real gender bias.
TREATMENT OF SEVERS
There are several key facets to the treatment of Sever’s disease in children with heel pain. Footwear selection is critical as in our professional experience, these children are frequently wearing shoes with insufficient support. We acknowledge it is not the fault of the parents as they are not expected to understand the requirements of the shoes that they purchase for their children. They are guided by the footwear assistants who always mean well but are not trained in bio mechanics or podiatry related issues. We will usually supply parents with 2 to 3 choices of shoe brands that we feel will best suit your child’s needs. Usually, with Severs disease, we will select a shoe with the correct level of support and rigidity in the required parts of the mid sole, and also the required level of cushioning in the heel area, to relieve the heel pain symptoms.
Please note that Sever’s is a condition that children grow out of following adolescence and usually before the foot stops growing. During this phase the sports podiatrist can provide comfort and relief of heel pain symptoms using tried and tested treatment protocols.
ORTHOTICS FOR SEVERS DISEASE
Some children with heel pain are prescribed orthotics to relieve the symptoms associated with Severs disease. The sports podiatrist will determine your child’s suitability for orthotics following the treadmill assessment and the replay of the video, showing your child’s foot function and bio mechanics. We find that a combination of firm support and cushioning is best when it comes to designing and manufacturing the orthotics themselves. If the orthotics are too soft then they don’t keep shape and therefore the foot falls or collapses, into the original position. In fact, these soft orthotics create an unstable environment beneath the feet, and this can cause muscles and tendons to “work harder” leading to further stress on these foot structures.
We understand the costs involved in prescription orthotics and so we don’t rush in or over prescribe them. Childrens feet are also growing quickly and so we are mindful that your child may only get 12 – 18 months of use from the inserts. To this end, we explore the other treatment options first and will recommend the orthotics if we deem necessary.
At Sydney Heel Pain Clinic we use a 3D scanner to capture your child’s foot shape, instead of a plaster cast. The scanner is extremely accurate and allows us to fit your child with an orthotic that matches his / her foot shape with precision. Your child will always be comfortable in the orthotics and the heel pain symptoms will subside quickly, if they do need them. We monitor progress and will carry out complimentary follow up appointments / orthotic adjustments if required (these appointments are rare as the lab we use have years of experience and execute the job with extreme accuracy).
We can have orthotics made from Carbon Fibre, polypropylene, EVA and now Nylon 12 which are made using a 3D printer.
If you feel like your child has heel pain or Severs disease and you would like them assessed for prescription orthotics, please feel free to send us an on line enquiry or call us on 93883322.
CALF STRETCHES FOR SEVERS
Children with heel pain from Severs Disease usually present to the sports podiatrist with tightness in the calf muscles. If this is not addressed then the Achilles Tendon will continue to pull hard on the growth plate, at the back of the heel bone and heel pain will persist. When you and your child come to the clinic for assessment we will demonstrate the ideal calf stretches and have your child perform them while in the room. We will also provide you with a complimentary Sydney Heel Pain Clinic mobile phone application which contains all the information you need to know about treating Severs disease, including how to perform the stretch. Because children are young and hence very healthy, they usually respond well to the stretching techniques and their range of motion in the ankle improves quickly.
During the consultation we will let you know if we want your child to have x rays taken. These are not always required when it comes to the management of Severs disease and are not always of use. We also take foot measurements and will advise on the use of heel lifts. Some children will benefit from the use of these lifts inside their shoes, to relieve heel pain. We have 3mm, 5mm, 7mm or 9mm heel lifts. Anything higher is difficult to fit inside the shoes. If necessary, we can request the boot maker to add some material to the outside of the shoe under the heel. These lifts are only used for a given period of time and do not form part of the long-term management of Severs.
If your child has day to day symptoms of heel pain from Severs we can also talk about the use of heat packs or cold compress. There is often some inflammatory change within the heel so the use of these remedies is sometimes beneficial.
We tend to advise that your child be careful if walking barefoot or frequently with thongs. These issues will affect the pull on the growth plate in the heel and can certainly increase the symptoms of heel pain in children who have been diagnosed with Severs disease.
We take the position that strengthening exercises should be avoided in cases of Severs. We don’t believe that the foot or ankle is weak and so loading it isn’t necessary. In fact, if your child has heel pain and they attempt to load the foot in order to strengthen the ankle joint, they risk increasing the stress on the growth plate and this can lead to further irritation, and an increase in heel pain symptoms. We will assess your child during consultation and will let you know if there are any weaknesses in the foot, ankle or lower leg.
We have a series of case studies relating to Severs disease in children that we have treated in the clinic on the following pages and you may wish to read these to obtain more information. https://www.sydneyheelpain.com.au/case-studies/
Written by Karl Lockett
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