Calcaneal Apophysitis (Severs Disease)

Question 1

What is Severes Disease/ Calcaneal Apophysitis

Answer 1

Severs Disease/Calcaneal Apophysitis is an overuse injury due to the result of Increased traction and repetative microtruama being placed on the Calcaneal Apophysis (Posterior aspect of the Calcaneus where the Achillies Tnedon Inserts)

Increased traction impact by the Plantar Fascia, Calf muscles and Achillies Tendon cause tiny avulsion fractures of the Apophysis followed by inflammation

Question 2

Why is this pathology associated with children aged between 8-15 years old

Answer 2

Between the ages of 8-15 The Physis (Calcaneal Growth Plate) is open.

When the growth plate is irritated is undergoes stress that leads to micro trauma.

After periods of rapid growth and increased activity, the force exerted by the Achilles tendon on the Calcaneal Aphophysis intensifies

Active children particularly during the pubertal growth spurt or at the beginning of a sport season often suffer with this condition

Growth is directly proportional to the amount of stress placed on the calcaneal growth plates.

Question 3

What are the Signs and symptomns for Calcaneal Apophysitis

Answer 3

Increased Pain upon Weight Bearing (Particularly Running and Jumping)

Tenderness Medial and Lateral Heel Compression

Limited ankle dorsiflexion range secondary to tightness of the Achilles tendon

Antalgic Gait/Patient may walk with a limp or exhibit a forceful heel strike and decreased stance phase.

Question 4

What Clinical examinations would you conduct to aid diagnosis

Answer 4

• Tenderness on palpation.
• Passive dorsiflexion test of the ankle: shows a decrease in dorsiflexion.
• Squeeze test: Mediolateral compression of the calcaneal growth plate to elicit pain in Sever’s disease. Performed over the lower one-third of the posterior calcaneus. This test is the most important to diagnose calcaneal apophysitis.
• Standing tiptoe aggravates the heel pain.
• Biomechanical abnormalisites - Pes Cavus, Pes Planus

Question 5

What are the management options for Severs Disease

Answer 5

Reduction in activity levels until symptomns decrease

Ice application 10-15 mins daily aid with inflamattion

Heel lifts, heel cups, and heel pads can reduce traction forces on the apophysis, thereby alleviating pain (i.e. raise heel, change angle of ankle joint reduce dorsiflexion)

Calf Stretching (reduce tensionon the Achillies) and Strengthening excercises to strengthen the adjcent muscles and reduce workload on achillies (Gastroc soleus complex) Calf raises, eccentric loading

Compliance may be better seen with a shoe with built in design features:
So for instance a more pronounced heel to to drop to reduce traction at the achillies or a cusioned heel counter to avoid irritation. It could also have some form of anti pronatory design like medial posting

Question 6

Explain how a heel raise works to rellieve heel pain in severs disease

Answer 6

Heel raise
Elevates the Calcaneus positioning it closer to the origin of the achillies reducing the tensile load in the achillies tendon which reduces traction at the apophsyial growth plate