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Updated: Sep 19 2023

Sever's Disease


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  • summary
    • Sever's Disease is a common idiopathic condition caused by overuse injury of the calcaneal apophysis in a growing child that presents with posterior heel pain. 
    • Diagnosis is made clinically with tenderness over the calcaneal apophysis with foot radiographs showing sclerosis and fragmentation of the calcaneal apophysis. 
    • Treatment is usually activity modifications, stretching of the heel cord and NSAIDs as the condition typically resolves over time. 
  • Epidemiology
    • Demographics
      • commonly seen in immature athletes participating in running & jumping sports
        • frequently seen just before or during peak growth
  • Etiology
    • Mechanism
      • exact etiology is unknown
      • thought to be due to traction apophysitis and repetitive microtrauma experienced during gait (similar to Osgood Schlatter's Disease)
  • 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
  • Prognosis
    • Natural history
      • self-limiting entity that resolves with maturation and the closure of the apophysis
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