As the Winter sport season is now well and truly underway, we are starting to see some of the more common overuse injuries affecting children and adolescents. Over the next few weeks, we are going to be looking at the more common musculoskeletal conditions affecting children, starting this week with Sever’s disease.
Sever’s disease is the common name for calcaneal apophysitis. It is a common cause of heel pain in childhood and early adolescence, and often occurs in children who are highly active, particularly in sports involving running and jumping.
Sever’s disease occurs when the bones in the lower leg (the tibia and fibula) grow more quickly than the Achilles tendon (the large tendon attached to the heel). The growth of the bones can cause the tendon to become very tight, and during exercise such as running and jumping, this tightness can place a lot of pressure at the back of the heel and lead to the heel bone becoming sore and swollen.
Sever’s disease most commonly affects children between the ages of 8 and 14 years, when growth spurts are beginning. Painful symptoms are most likely caused by the pulling of the Achilles tendon at the attachment point or by increased impact at the heel (for example, hitting the ground hard), or a combination of both.
Image credit: https://inlinephysio.com.au/a-focus-on-severs-disease/
Symptoms of Sever’s disease include:
- heel pain during physical exercise, especially activities that require running or jumping
- worsening of pain after exercise
- limping – often in the morning, or during or after sport
- a tendency to tip toe
- pain or tenderness in the heel, during or after exercise
- swelling around the heel bone
Why does this happen?
The Achilles tendon attaches to the back of the heel, just next to the growth plate and puts force through this area during gait. If this force becomes too great, this growth plate can become irritated, starting a painful inflammatory process.
While increased activity is definitely a predisposing factor, other things may also contribute, such as; reduced movement of the ankle, abnormal foot movements when walking and tight calf muscles. It is also possible that Sever’s disease will appear with no apparent cause.
Other factors that can contribute to Sever’s disease include changes in:
- height and weight
- how much physical activity they are doing – this may be an increase in volume, intensity or frequency or activity and commonly occurs:
as one sports season ends and another starts,
where there is crossover in sport,
when a child starts to train and play for a team (the volume of activity increases with multiple weekly training sessions and a game),
when they are involved in a sports carnival which involves playing multiple games in one day or over a number of days
- frequency of physical activity
- the type of physical activity – such as starting a different activity or returning to a physical activity after break
- equipment or external factors – such as a change in shoes
Physical attributes such as flat foot posture, decreased ankle dorsiflexion range of motion, tight calf muscles or increased body weight can also contribute to the development of Sever’s disease.
Sever’s is a self-limiting condition, which means that symptoms often ease with time, without treatment. However, your health care professional can manage the symptoms so that the child can continue to take part in physical activity. Pain usually settles within 6-12 months, but sometimes symptoms may persist for up to 2 years.
There is no specific treatment for Sever’s disease, but the child should learn how to manage the symptoms. Continuing sport or physical activity is not harmful, but may make the pain worse, so it may be better to temporarily stop or modify activities that cause pain.
Treatment may include:
- education on how to self-manage the symptoms and flare ups
- activity modification – limiting the pain-inducing activities for a short period of time may be beneficial
- load management – this may initially include a period of decreased or modified load, however load is important for the tendon, heel bone and apophysis so after the initial flare, load needs to be managed to make sure these remain healthy
- avoid stretches and “eccentric” exercises (such as lowering your heel over a step or jumping and hopping) in the initial phase
- orthotics and heel raises to improve biomechanics and reduce load on the Achilles
- ice/cold packs
- pain-relieving medications
Physiotherapists are extremely skilled at managing these types of musculoskeletal conditions, so be sure to contact us to assist with any concerns you may have.