Will Severs Disease Often Call For Surgery Treatment?

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Overview

Sever's disease is a common cause of heel pain in adolescence. Developing, physically active ?kids? are more prone to Sever's. During puberty the calcaneus consist of two developing sites of bone known as ossification centres. These two areas are seperated by an area of cartilage known as the calcaneal apophysis. The Achilles tendon attaches the triceps surae (calf muscles) to the calcaneus (heel bone). As a child grows the calcaneus grows faster than the surrounding soft tissue, which means the Achilles tendon is pulled uncomfortably tight. This increase in strain causes inflammation and irritation of the calcaneal apophysis (growth plate) which is known as Sever's Disease. The pain is exacerbated by physical activities, especially ones involving running or jumping. Sever's disease most commonly affects boys aged 12 to 14 years and girls aged 10 to 12 years, which corresponds with the early growth spurts of puberty.

Causes

The calcaneal apophysis develops as an independent center of ossification (possibly multiple). It appears in boys aged 9-10 years and fuses by age 17 years, it appears in girls at slightly younger ages. During the rapid growth surrounding puberty, the apophyseal line appears to be weakened further because of increased fragile calcified cartilage. Microfractures are believed to occur because of shear stress leading to the normal progression of fracture healing. This theory explains the clinical picture and the radiographic appearance of resorption, fragmentation, and increased sclerosis leading to eventual union. The radiographs showing fragmentation of the apophysis are not diagnostic, because multiple centers of ossification may exist in the normal apophysis, as noted. However, the degree of involvement in children displaying the clinical symptoms of Sever disease appears to be more pronounced. In a study of 56 male students from a soccer academy, of whom 28 had Sever disease and 28 were healthy control subjects, findings suggested that higher heel plantar pressures under dynamic and static conditions were associated with Sever disease, though it was not established whether the elevated pressures predisposed to or resulted from the disease. Gastrocnemius ankle equinus also appeared to be a predisposing factor.

Symptoms

Sever's disease usually develops gradually. The pain from Sever's disease is often intermittent and localized to the area where the Achilles tendon attaches to the calcaneus. Swelling may be noted in this area. There can be tenderness on squeezing the calcaneus or pain when trying to stretch the calf muscles. Occasionally there is night pain. As Sever's disease progresses there can be continuous pain.

Diagnosis

This can include physical examination and x-ray evaluation. X-rays may show some increased density or sclerosis of the apophysis (island of bone on the back of the heel). This problem may be on one side or bilateral.

Non Surgical Treatment

The treatment of Sever's disease depends upon the severity of symptoms experienced by the patient. Care is initiated with a simple program of stretching and heel elevation to weaken the force applied to the calcaneus by the Achilles tendon. If stretches and heel elevation are unsuccessful in controlling the symptoms of Sever's disease, children should be removed from sports and placed on restricted activities. Mild Symptoms. Wear a 3/8 heel lift at all times (not just during physical activity). It is important to use a firm lift and not a soft heel pad. Calf stretches 6/day for 60 seconds each. Calf stretches are best accomplished by standing with the toes on the edge of a stretching block. Moderate Symptoms. Follow the directions for minor symptoms and decrease activity including elimination of any athletic activity. In addition to stretching by day, a night stretching splint can be worn while sleeping. Severe Symptoms. Follow the directions for mild and moderate symptoms. Children should be removed from sports activities such as football, basketball, soccer or gym class. A below knee walking cast with a heel lift or in severe cases, non-weight bearing fiberglass cast, may be indicated for 4-6 weeks. The cast should be applied in a mildly plantar flexed position. Cam Walkers should not be used for Sever's Disease unless they have a built in heel lift.

Prevention

Having Sever?s disease does not predispose children or teens to any other condition, nor is it a permanent problem. It is self-limiting, and when treated, the pain and other symptoms will abate within a few weeks. Once the growth plate has finished growing, Sever?s disease will resolve and won?t recur. It is important to continue to treat any underlying foot conditions and to avoid any long periods of inactivity.
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