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https://upload.orthobullets.com/topic/4074/images/sever.jpg
Introduction
  • Overview
    • common cause of heel pain 
    • thought to be an overuse injury of the calcaneal apophysis in a growing child
  • Epidemiology 
    • commonly seen in immature athletes participating in running & jumping sports
      •  frequently seen just before or during peak growth
  • Mechanism
    • exact etiology is unknown
    • thought to be due to traction apophysitis and repetitive microtrauma experienced during gait (similar to Osgood Schlatter's Disease)
  • Natural history
    • self-limiting entity that resolves with maturation and the closure of the apophysis
Relevant Anatomy
  • The calcaneal apophysis experience significant force from combination of both
    • direct impact onto the heel during the heel strike phase of gait
    • opposing tension forces generated by the plantar fascia and the pull of the gastrocsoleus complex
Presentation
  • Symptoms
    • pain in the area of the calcaneal apophysis in an immature athlete
    • pain increased with activity or impact 
    • stretch of the triceps surae exacerbates heel pain
    • can display warmth, erythema, & swelling
  • Physical exam
    • tight Achilles tendon
    • positive squeeze test (pain with medial-lateral compression over the tuberosity of the calcaneus)
    • pain over the calcaneal apophysis
Imaging
  • Radiographs
    • diagnosis is clinical as there is no established diagnostic criteria  
    • sclerosis can be present in both patients with and without calcaneal apophysitis
    • fragmentation is more frequently seen in patients with Sever's disease  
    • helpful to rule out other causes of heel pain (osteomyelitis, calcaneal bone cysts)
  • MRI
    • can help localize inflammation to apophysis
    • can rule out disorders of the body of the os calcis (stress fracture, lytic lesion, osteomyelitis)
  • Other
    • bone scan can show increase uptake at the apophysis, but is typically not helpful in diagnosis
Treatment
  • Nonoperative
    • symptomatic treatment
      • modalities include
        • activity modification
        • Achilles tendon stretches (can help decrease recurrence)
        • ice application before and after athletic endeavors
        • use of heel cups or heel pads
        • NSAIDs
        • short leg cast immobilization of persistent pain
      • outcomes
        • recurrence is common
  • Operative
    • there is no role for operative treatment
 

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