Calcaneal apophysitis or Sever’s Disease as it is better known, is regularly seen amongst active adolescents experiencing growth advancements between the ages of eight and fourteen. Once thought as an inflammation of the apophysis at the immature athlete’s heel, Sever’s is now regarded as a non articular, non-inflammatory repetitive and chronic injury to the trabecular metaphyseal bone during active remodelling created by traction at the tendo achillies/calcaneal junction- due to the rapid proliferation of growth plates, the apophysis is seen to be more susceptible to injury (Scharfbillig, Jones, & Scuter, 2008).
The young athlete, particularly those who are experiencing both physical and physiological changes in maturity can be at increased risk of sports related injury. Rapid growth has been linked to poor dynamic balance, increase in BMI and a misunderstanding by coaches of how to best work with this period of a young athletes life. Calcaneal apophysitis or Sever’s Disease as it is better known, is regularly seen amongst active adolescents experiencing growth advancements. Once thought as an inflammation of the apophysis at the immature athlete’s heel, Sever’s is now regarded as a non-inflammatory repetitive and chronic injury to the trabecular metaphyseal bone during active remodelling.
The presence of Sever’s in an individual has been shown to decrease the subjective ‘happiness’ levels and reduce physical activity participation when compared to children without symptoms of the condition (James, Williams, & Haines, 2013).

Signs and Symptoms
Pain will usually follow the pathway of non muscular pathology with activity increasing localized pain felt at the insertion of the achilles tendon. Additionally, there may be restricted dorsiflexion range of motion at the ankle and trigger points or tightness within the Tricep Surae, Gastrocnemius or Soleus as muscle growth is thought to lag behind that of bone growth resulting in significant imbalance.
A child wearing poor footwear which does not accommodate their biomechanical needs, overtrains or trains in a way which detrimental to health  or has a foot type which places increased stress on the achilles tendon is at increased risk of developing severs. In a study of 85 patients it was found that most of the subjects were track and field participants with basketball, gymnastics and soccer following closely behind (Scharfbillig, Jones, & Scuter, 2008). Histological and radiographic investigations have failed to show substantial evidence which backs the theory of an increased inflammatory process during suspected severs conditions however increased radiodensity is common (Hussain, Hussain, Hussain, & Hussain, 2013)
Parents of young athletes will commonly comment on a child’s gait including a limp during sport or training and complaints of pain while barefoot.
Of course the best clinical test to perform is the squeeze test or calcaneal compression to illicit painful symtoms.

Differential Diagnosis
Musculoskeletal – Through the use of imaging and detailed patient history the following conditions may also be obtained as a potential diagnosis.
Achilliobursiitis – Pain due to inflammation associated with the achillies tendon
Tenosynovitis – Achilles tenosynovitis is a condition in which there is inflammation and degeneration of the tendon’s outer sheath or layer.
Ankle Sprains – Layman’s term for inversion or eversion injury to the tendons, ligaments and structures of the foot.
Retrocalcaneal Exostosis – overgrowth of bone on the back of the heel
Plantarfascitis – overuse or injury of the plantar fascia of the foot.

Infective – Infective or autoimmune conditions are usually associated with increases in temperature, systemic sickness and night pain.
Rheumatoid Factors – Systemic autoimmune condition which may lead to inflammation within the joints.
Tumors – Abnormal growth of benign or malignant nature
Osteomylitis- Infection of the bone
Tuberculosus- Contagious condition which effects the bones and joints.

Treatment:
Patient load management is most important to be effective in reducing pain at the heel. In the early stages or reactive stages of Severs pain general first aid practices should be completed including; rest, localized icing/cold therapy, compression, elevation and referral to allied health professional such as podiatrist, physiotherapist, chiropractor or paediatrician.
Comparison of treatment modalities in the literature is not something investigated thoroughly but a multi-faceted approach seems to anchor the best results. Reducing sporting activity, offloading through heel lifts or orthotics (if deemed necessary), stretching of the tricep surae and the use of night splints, self massage/ foam rolling and shock absorption padding seem to be the most trialled and tested modalities to combine.
A 2013 Literature review by James, Williams and Haines showed that there was little evidence to support the use of orthotics and heels lifts as a sole modality in children with calcaneal apophysitis pain. Taping and padding was shown to have a positive effect in the reduction of pain in the acute and immediate stages of acknowledgement with a p-value 0.001, however this particular study also included adults with heel pain and should be considered carefully when applying to children (James, Williams, & Haines, 2013).

Prevention:
It is known that injury is a major barrier to sport participation, it is estimated that up to 50% of adolescent sport related injury is preventable. Balanced training has been seen to reduce lower limb injuries as well as multiple intervention approaches with warm up, neuromuscular control strategies and cool down.

Conclusion:
In conclusion, the ability to prevent Sever’s seems to be a difficult issue to address. To try and tell an active child to stop being active before there is anything wrong with them is not the business I want to be in, that’s for sure!
For that matter, reducing structured sporting activity may only be one side of issue. If a child is active it is not only structured activity which needs to be looked at – walking to and from school, PE, morning tea, lunch time and play dates are all time where a child can be increasing the traction over the apophysis.
Once the condition has been identified it’s another story and what is best for the patient should take over any emotional response you have to limiting their activity. I had found being able to monitor a child’s activity levels and keeping them liable for what they are doing to be most effective, additionally, it provides as a good education tool when explaining why the pain is increasing or decreasing. Below is an example of the document I give to patients to monitor their activity levels.

	Prescribed Exercises	Worst Pain -/10	Best pain   -/10	Other Activity
Tuesday	YES	1/10	0/10	Soccer
Wednesday	YES	3/10	1/10	PE
Thursday	YES	3/10	0/10	Footy
Friday	NO	8/10	2/10	Basketball
Saturday	NO	8/10	2/10	Basketball
Sunday	NO	10/10	5/10	Chasy

Patient Signature………………………………….       Parent Signature…………………………………..

Practitioner Signature……………………………………………………………

An example such as the one above may play out in the clinic such as “ At the start of the week I was really good with only a little bit of pain, but because the pain was gone I stopped icing and doing the stretches and my pain became really bad”.
By having a sheet similar to this available it also allows that the modality you are using to treat severs is effective when being completed and places more responsibility on the patient and their guardian for the outcome of their health.
I hope you have enjoyed reading, in 2weeks we will look at an overview of plantar warts.
If you have any questions please feel free to comment below

Jackson McCosker
Director /Chief Editor

References

Brukner, P. (2013). Bruker and Khan’s Clinical Sports Medicine. North Ryde: McGraw-Hill Education Pty Ltd.

Hussain, S., Hussain, K., Hussain, S., & Hussain, S. (2013). Sever’s Disease: A Common Caause of Paediatric Heel Pain. BMJ CASE REP , 1-2.

James, A. M., Williams, C. M., & Haines, T. P. (2013). Effectiveness of Interventions in Reducing Pain and Maintaining Physical Activity in Children and Adolescents with Calcaneal Apophysitis (Sever’s Disease): A Systematic Review. Journal of Foot and Ankle Research , 6 -16

Michaud, T. (2011). Human Locomotion: the Conservative Management of Gait-Related Disorders. Newton: Newton Biomechanics.

Scharfbillig, R. W., Jones, S., & Scuter, S. D. (2008). Sever’s Disease: What Does the Literature Really Tell Us? Journal of the American Podiatric Medical Association , 212 – 223.

Wiegerinck, J., Yntema, C., Brouwer, H. J., & Struijs, P. A. (2014). Incidence of Calaneal Apophysitis in the General Population. European Journal of Pediatrics , 677 – 679.