The calcaneal apophysis is a growth center where the Achilles tendon and the plantar fascia attach to the heel. It first appears in children aged 7 to 8 years. By ages 12 to 14 years the growth
center matures and fuses to the heel bone. Injuries can occur from excessive tension on the Achilles tendon and the plantar fascia, or from direct impact on the heel. Excessive stress on this growth
center can cause irritation of the heel, also called Sever?s disease.
Sever?s disease only occurs during a certain period of pre-adolescence, when the heel bone is going through a rapid growth spurt. In girls, this typically occurs around 8 to 10 years of age, and in
boys, between ages 10 and 13. Sever?s disease is more common in active, athletic children. The condition is difficult to prevent completely, but changing the type and amount of physical activity when
your child is experiencing pain will help.
The patient complains of activity related pain that usually settles with rest. On Examination the heel bone - or calcaneum - is tender on one or both sides. The gastrocnemius and soleus muscles (calf
muscles) may be tight and bending of the ankle might be limited because of that. Foot pronation (rolling in) often exacerbates the problem. There is rarely anything to see and with no redness or
swelling and a pain that comes and goes mum and dad often wait before seeking advice on this condition. The pain may come on partway through a game and get worse or come at the end of the game.
Initially pain will be related only to activity but as it gets worse the soreness will still be there the next morning and the child might limp on first getting up.
To diagnose the cause of the child?s heel pain and rule out other more serious conditions, the foot and ankle surgeon obtains a thorough medical history and asks questions about recent activities.
The surgeon will also examine the child?s foot and leg. X-rays are often used to evaluate the condition. Other advanced imaging studies and laboratory tests may also be ordered.
Non Surgical Treatment
Treatment is primarily directed towards reducing the amount of stress to the heel. Often a heel lift, is placed in the shoe to reduce the pull of the Achilles tendon on the apophysis. Gel or
cushioned heel cups may also be helpful in reducing micro trauma to the heel. Orthotic control may also be indicated when a pathologic condition exists in the foot that may be contributing to the
increased heel stress. Occasionally, it becomes necessary for adequate healing, to rest the area completely. This can be accomplished either by complete elimination of all strenuous activities, or by
using a walking cast or crutches. Often simply reducing activity levels is adequate. Your physician will discuss the best treatment plan with you and your child.
The following exercises are commonly prescribed to patients with Severs disease. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally,
they should be performed 1 - 3 times daily and only provided they do not cause or increase symptoms. Your physiotherapist can advise when it is appropriate to begin the initial exercises and
eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no
increase in symptoms. Calf Stretch with Towel. Begin this stretch in long sitting with your leg to be stretched in front of you. Your knee and back should be straight and a towel or rigid band placed
around your foot as demonstrated. Using your foot, ankle and the towel, bring your toes towards your head as far as you can go without pain and provided you feel no more than a mild to moderate
stretch in the back of your calf, Achilles tendon or leg. Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free. Calf Stretch with Towel. Begin this
exercise with a resistance band around your foot and your foot and ankle held up towards your head. Slowly move your foot and ankle down against the resistance band as far as possible and comfortable
without pain, tightening your calf muscle. Very slowly return back to the starting position. Repeat 10 - 20 times provided the exercise is pain free. Once you can perform 20 repetitions consistently
without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms. Bridging. Begin this exercise lying on your back in the
position demonstrated. Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for
2 seconds then slowly lower your bottom back down. Repeat 10 times provided the exercise is pain free.