American Family Physician Sever's Disease and Other Causes of Heel Pain in Adolescents CHRISTOPHER C. MADDEN, M.D., University of Nebraska Medical Center, Omaha, Nebraska MORRIS B. MELLION, M.D., Sports Medicine Center, Omaha, Nebraska Sever's disease, or apophysitis of the calcaneus, is a common but frequently undiagnosed source of heel pain in young athletes. This condition frequently occurs before or during the peak growth spurt in boys and girls, often shortly after they begin a new sport or season. Sever's disease often occurs in running and jumping sports, particularly soccer. Patients present with intermittent or continuous heel pain occurring with weight bearing. Findings include a positive squeeze test and tight heel cords. Severs disease cannot be diagnosed radiographically. The condition usually resolves two weeks to two months after the initiation of conservative treatment, which may include rest, ice application, heel lifts, stretching and strengthening exercises, and, in more severe cases, nonsteroidal anti-inflammatory drugs. Sever's disease, or calcaneal apophysitis, was first described in 1912 ns a cause of heel pain and tenderness localized to the posterior aspect of the calcaneus in physically active, overweight children and adolescents.'-^ Sometimes referred to as Osgood-Shlatter disease of the heel, the disease is a traction apophysitis occurring at the secondary calcaneal ossification center that appears between the sixth and eighth years in most children.'-'"*' The secondary calcaneal center begins with the ossification of several fragments and eventually forms a vertically oriented C-shaped growth plate at the posterior border of the calcaneus.^** The insertion of the Achilles tendon over the posterior and inferior surfaces of the calcaneus subjects the vertically oriented epiphysis to strong November 1,1996 shearing forces during gastrocnemius contractions.'' " The disease occurs most commonly during the early part of the accelerated growth spurt. Fusion of the epiphysis to the main body of the calcaneus occurs between the ages of 12 and 15 years.''-'^ Sever's disease is now recognized as a common source of heel pain in young nonobese athletes. The condition responds well to conservative measures.^^ Illustrative Case A physically active nine-year-old boy complained of insidious onset of bilateral heel pain occurring after sports activity, particularly soccer, over the previous two years. The pain was associated with weight bearing and had recently become more constant. Current treatment consisted of ice applications. On physical examination, the patient had a mildly increased valgus of both lower extremities. The insertion of the Achilles tendon was markedly tender over the posterior calcaneus bilaterally. Mediolateral compression (the "squeeze test") of the calcaneus anterior to the Achilles tendon insertion elicited pain bilaterally. Heel cord flexibility was significantly limited with the knee extended. Radiographs demonstrated increased density, irregularity, fragmentation and sclerosis at the calcaneal apophysis Based on the child's history and the clinical findings, Sever's disease was diagnosed. The radiographic evaluation ruled out other pathology. The patient was referred to a physical therapist for a rehabilitative exercise program that focused on 1995 American Family Physician Sever's Disease improving flexibility. The use of Tuli's heel cups was also recommended. At the follow-up examination four weeks later, the patient was greatly improved. He was using his heel cups and was playing soccer without difficulty. He had no tenderness over the Achilles tendon insertion, a negative squeeze test, and increased flexibility bilaterally. The patient was instructed to continue rehabilitation exercises and to come to the clinic for follow-up visits as needed. Etiology The etiology of Sever's disease has not been established, but the main predisposing factors appear to be abnormal stress at the epiphysis, biomechanica! abnormalities of the ftKit and overactivity with resultant microtrauma.^-'^^*' Prepubertal long-bone growth often exceeds muscle and tendon growth. As a result, the flexibility of the heel cords {Achilles, posterior tibial and peronea! tendons) is reduced, and ankle dorsiflexion may diminish to less than 10 degrees. A child may have congenital or acquired shortening of the triceps surae.'^The plantar fascia may also be tight. These flexibility limitations may contribute to the occurrence of abnormal stresses at the calcaneal apophysis with weight bearing.'* Acute trauma, such as a violent heel strike in a basketball player or a gymnast, may be a triggering event.'*^ Biomechanical abnormalities that often occur concomitantly with Sever's disease include forefoot varus, hallux valgus, pes cavus and pes planus.**'^^''' All of these structural faults may have associated poor shock absorption that may expose the heel to abnormal forces." Finally, the most significant etiologic factor in Sever's disease is overuse and microtrauma in sports that require repetitive loading of the heel, such as soccer or running.^''•'•'' All dimensions of an increased athletic workload, including duration, intensity and frequency, may contribute to the problem. 1996 FIGURE 1. R.Klioi;i-,iph ol thf It-ft lieol oi .^ uinv- year-old boy with Sever's disease. AUhough the radiograph demonstrates increased density, irregularity, fragmentation and sclerosis at the calcaneal apophysis, these radiographic findings are considered to be within the normal range. History and Presentation The typical patient with Sever's disease is a young athlete who is having a growth spurt and who complains of intermittent or continuous heel pain that occurs with weight bearing shortly after the child begins a new sport or season.''''" The problem usually develops in girls eight to 10 years of age and boys 10 to 12 years of age. The heel pain, which can be bilateral or unilateral, is usually precipitated by some type of weight-bearing exercise.'' Pain is usually absent when the child gets up in the morning, increases with activity and improves with rest. Hard surfaces and poor-quality or worn-out athletic shoes contribute to increased symptoms. The child may have a liistory of direct trauma or injury to the heel.^" The pain may become so intense that the child must stop athletic participation and must occasionally use crutches.'^ ln addition to soccer, sports frequently associated with Sever's disease include gymnastics, football, baseball, ice hockey, tennis, figure skating, ballet, tae kwon do and various running sports.''""'^ No longterm sequelae of Sever's disease have been Physical Examination The physical examination may reveal forefoot varus, hallux valgus, pes cavus or pes planus. Forefoot pronation is most common.** '^'""^ Although gait may be normal, the patient may walk with a limp or exhibit a forceful heel strike.'*'" Standing volume 54, number 6 American Family Physician FIGURE 2. Mediolateral heel compression, or the "squeeze test," performed over the lower onethird of the posterior calcanetis. The test is positive if the compression elicits pain. (Top) Lateral view. {Bottom) Posterior view. Achilles tendon Pre-Achilles fat pad, Subcutaneous bursa Retrocalcaneal bursa Epiphysis Apophysis Calcaneus — Heel fat pad Plantar fascia FIGURE 3. Normal heel anatomy. Note that the apophysis is C-shaped and occupies the posteroinferior aspect of the heel, with the Achilles tendon inserting posteriorly. November I, 1996 on tiptoe may aggravate the heel pain (positive Sever's sign)."'^ Erythema, swelling or other skin changes are uncommon and suggest different pathologic processes/^-'^ Tenderness to palpation may be present at or just anterior to the insertion of the Achilles tendon along the posterior border of the calcaneus.' Mediolateral heel compression, or the squeeze test, performed over the lower one-third of the posterior calcaneus elicits pain {Figure 2).''Heel pain may be mild to severe, and it may prevent weight bearing. Heel cord flexibility is tested by passive dorsiflexion of the foot with the knee in extension. It is often reduced to less than 10 degrees, and testing may elicit pain.**-^^ Sever's disease cannot be diagnosed radiographically.^ '^ The fragmentation, sclerosis and increased density of the apophysis that characterize Sever's disease are considered normal radiographic findings'^ {Figure 3). The fragmented appearance occurs because the apophysis evolves from several ossification centers.' As the centers mature, they fuse together and form a C-shaped growth plate located over the posteroinferior border of the calcaneus. The borders of the apophysis may appear fluffy or well defined.^' As the apophysis matures, calcifications appear that extend to the main calcaneal body. Fusion of the apophysis to the body takes place by about 15 years of age, after which Sever's disease no longer occurs." Radiographs may rule out other possible causes of heel pain, such as tarsal coalition, fracture, bone cyst or tumor.-* Since patients with Sever's disease have normal findings, radiographs are indicated only for the differential diagnosis, for patients who do not respond to conservative treatment and for patients with an atypical presentation. Differential Diagnosis The diagnosis of heel pain is challenging because many structures may be involved {Figure 3). Conditions that can present as heel pain in a young athlete are listed in 1997 American Family Physician Sever's Disease TABLE 1 Differential Diagnosis of Heel Pain in Young Athletes Conditioii Presentation Evaluation Radiology Sever's disease Growing athlete, commonly between 8 and 12 years old Follows participation in a sport, especially soccer Unilateral or bilateral heel pain that increases with activity, particularly on hard surfaces Squeeze test positive Tight heel cords Tenderness on palpation at the insertion of the Achilles tendon Sclerosis and fragmentation of the calcaneal apophysis (findings that are within the radiographic normal range) Plantar fasciitis Usually unilateral Pain and/or local tenderness over the pmximal medial arch and/ or heel with weight bearing, especially after rising in morning Pain sometimes relieved with prolonged activity Tenderness on palpation over the medial calcaneal tubercle (insertion ttf the plantar fascia) Diffuse medial heel and/or arch pain with palpation Often, tight heel cords Radiograph may show anteroinferior calcaneal spur Achilles tendinitis Stiffness (early) of the Achilles tendon, which progresses to pain (later) with continued activity Crepitus or swelling over the Achilles tendon Tenderness and/or thickening on palpation over the body (middle section) of the Achilles tendon Tight heel cords Crepitus with passive range of motion I'ain increases with hopping Plain radiograph; loss of sharp anterior interface with pre-Achilles fat pad; calcification or osteophytes Ultrasound: tears, calcification CT and MRl scans: tears, thickening or degeneration of tendon Retrocaloaneal bursilis Aching pain and/or swelling anterior to the Achilles tendon following exercise Tenderness on palpation and/or swelling anterior to the Achilles tendon in the retnicalcaneal Radiograph may show loss of sharp definition of lucent (increased opacity) retnKalcaneal recess Posterior superior enlargement of os calsis ("hatchet heels") may be present Calcaneal stress fracture Participation in repetitive jumping and/or running sports Localized heel pain at fracture site Mild swelling Pain with mediolateral aimpression of calcaneal lx)dy Local pain at fracture site on palpation Radiograph may be normal or may indicate periosteal new bone formation or fine fracture line Bone scan can be used if the radiographic findings are negative Tarsal coalition Teenager or preteen complaining of diffuse arch pain Often, a liistory of recent ankle sprain or an increase in training intensity Rigid flat foot Subtalar tenderness Decreased subtalar mobility Occasionally, rigid peroneal spasm Radiograph (oblique view is often helpful): "bars" between tarsal bones CT scan (definitive): union of tarsal bones Tarsal tunnel syndrome Aching or burning pain and paresthesia (medial or lateral) that increase with weij^ht bearing Symptoms may coexist with plantar fasciitis Often, hyperpronated or flat feet Painful area over the site of impingement Fo.sitive Tmel's sign: tapping at impingement site (behind or below medial malleolus) causes pain over the plantar nerve distribution Radiographs normal Can perform EMG/NCT 1998 volume 54, number 6 American Family Physician TABLE 1 continued Condition Presentation Evaluation Radiology Systemic disease (ankylosing spondylitis, Reiter's syndnime, juvenile rhc'uniatoid arthritis) Tumor Disease-specific symptoms Plantar fasciitis-like symptoms Often bilateral Morning stiffness Complete history and physical examination with comprehensive review of systems May order ESR, RF, HLA B27, urinalysis Radiograph: targe, fluffy heel spurs and enisions of the posterosuperior cortex of the calcaneus Refer to individual diseases for specific findings Pain of long duration Night pain Fever, malaise and/or anorexia Complete history with a review of systems CBC, ESR, radiographs, bone scan Radiograph: radiolucent mass, often not crossing joint margins; cystic mass Bone scan may be used Infection Puncture wound Night pain Erythema and/or swelling Fever, malaise and/or anorexia Enlarged posterosuperior calcaneal prominence Rubbing of footwear may increase pain Local pain History of forceful heel impact Heei pain that Increases with activity Walking barefoot or after rest is painful Often overweight Tenderness on palpation Soft tissue signs CBC, ESR Radiograph: normal or soft tissue swelling Posterior calcaneal prominence Subcutaneous bursa may be tender to palpation Radiograph (oblique view is often helpful): pt>ssibly, exostosis between the Achilles tendon and the calcaneus Swelling, ecchymosis, tenderness on palpation of the injured area Pain on palpation of heel pad Pain relief while on tiptoe Radiograph: normal or soft tissue swelling Pump bump (runner's bump). or calcaneal exostosis Contusion Heel fat pad syndrome Noncontributory CT - computed tomography; MRt = magnetic resonance imaging; EMC/NCT = clectromyography/newe conduction test; ESR = erythrocyte sedimentation rate; RF' = rheumatoid factor; HI A B27 ^ human leukocyte antigen B27 (blood test for ankylosing spondylitis and Reiter's syndrome); CBC = complete blood count. Derived from references 2,3,10,12,14.15 and 18. Table 1, along with factors that can help differentiate among theseproblems.^-^'"'^'^'^'" Management The initial treatment of Sever's disease consists of rest, ice application, use of heel Ufts, and stretching and strengthening exercises. Activities that cause symptoms should be stopped, k e should be applied to the heel for 25 minutes three times a day." Heel lifts (one-fourth to one-half inch) or viscoelastic heel cups can be used to decrease impact shock.^'^'*'^* Rehabilitation under the supervision of a physical therapist would include heel cord flexibility and dorsiflexor strengthening exerdses.^"" November 1,1996 Analgesics may not be warranted in mild occurrences, but in more severe cases or if symptoms do not improve, nonsteroidal anti-inflammatory drugs may be effective in reducing pain. The patient should also be instructed to wear supportive shoes with a solid heel counter and to avoid walking barefoot.^•''^ If the pain is severe enough to cause a limp, crutches may be used for symptom control.'-^ In addition to using heel cups and pads during acute stages, orthotics may be used to correct significant biomechanical abnormalities after symptoms resolve.'^ Follow-up should take place in two to four weeks.^"-^^Rarely, resistant cases of 1999 American Family Physician Sever's Disease Sever's disease may require the use of a short leg cast for two to four weeks.""' Corticosteroid injections are not recommended.""'"'Nighttime dorsiflexion splints, often a useful adjunct in the treatment of plantar fasciitis, may help relieve symptoms and may help maintain flexibility throughout the growth period of preadolescent athletes.'•'"*'''-'' lf the symptoms have not improved significantly on foUow-up, if there is an unusual presentation or if the etiology is unclear, calcaneal radiographs may be taken to rale out other pathology.''^ Symptoms usually resolve in a few weeks to tu'o months after tlierapy is initiated.^''' With proper treatment, most cases of Sever's disease resolve completely.'*' Return to activity may take place only when symptoms allow comfortable participation.^ Stretching and strengthening during rapid growth spurts may significantly reduce the incidence of Sever's disease.-' Good-quality athletic shoes with a shockabsorbent sole and firm heel counter will provide adequate support and help prevent injury. If a patient will be returning to sports after recovery, stretching and icing after activity may help prevent recurrence.''-'"* A patient information haiidont oti Sever's disease is provided ou page 2U04. REFERENCES 1. Micheli L]. The traction apophysitises. Clin Sports Med l%7;6:389-4()3. 2. Sever JW. Apophysitis of the os calcis. N Y Med J 3. Clain .MR, Hershman EB. Ovenist- injuries in children and adolescents. Physician Sportsmed 1989;I7: 111-23. Gregg JR, Das M. Foot and ankle problems in the prendoiescent and adolescent athlete. Clin Sports Medl982;l:131-47. Hughes ES. Painful heels in children. Surg Gynecol Obstet 1948:86:64-8. Stanitski CL. Combating overuse injuries: a focus on children and adolescents. Physician Sptirts Med 10. n. 12. 13. The Authors CHRISTOPHER C. MADDEN, M.D. is a family practice resident <it the University of Nebraska Medical Center, Omaha. Dr. Miidden received his medical degree from the University of Nebrnska Schmil of Medicine, Omaha. He designed and taught "Healthy Lifestyles," a program to introduce dnd encourage basic fitness and health principles in young Omaha teenagers. 14. 15. 16. 17. MORRIS B. MELLrON, M.D. is medical director at the Sports Medicine Center, Omaha, and clinical associate professor in the Department of Family Practice and Orthopedic Surgery at the University of Nebraska Medical Center. He also serves as adjunct associate professor for the School of Health, Physical Education, and Recreation at the tJniversity of Nebraska, where ho is the team physician for men's and women's sports. Dr. Mellion is a past president of the American Academy ol Family Fhysidans. 18. 19. 20. 21. Address conesptmdetice to Morris B. Mellioii, M.D., Medical Director. Sports Medicine Center, 2255 S. J32nd St.. Omaha. NE 68144. 2000 Shopfner CE, Coin CG. Effect of weight-bearing on the appearance and development of the secondary calcaneal epiphysis. Radiology 19fi6;8(i:2l)l-ft. 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Prevention and management of calcaneal apcphysitits in children: an ovenise syndrome. J Pediatr Orthop 1''87;7:34-8. Santopiotro F]. Foot and foot-relntcd injuries in the young athlete. Clin Spurts Med l988;7:563-89. Calliet R. Foot and ankle pain. 2d ed. Philadelphia: Davis, 1983:143. Mellion MB, Walsh WM Shelton GL. The team physicians handbook. Philadelphia: Hanley & Belfus, 1990:449-59. Wapner KL, Sharkey PF The use of night splints for treatment of recalcitrant plantar fasciitis. Foot Ankle 1991;12:135-6. Ryan J. Use of posterior night splints in the treatment of plantar fasciitis. Am Fam Physician 1995;52:891-8. Mayer FJ. Lower limb injuries in childhood and adolescence. In: Micheli LJ. Pediatric and adolescent sports medicine. Boston: Little. Brown, 1984:80-106. volume 54, number 6