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.
Heel pain is very common in children due to the fact they are cnstantly growing. In most children, the heel bone (the calcaneus) is not fully developed until the age of 14 or older. Until then, new
bone is forming at the growth plate of the foot (the apophysis, located at the back of the heel), an area which is softer than others due to its role in accommodating the growth. Repetitive stress on
the growth plate due to walking, running and sports causes inflammation in the heel area. Because the heel's growth plate is sensitive, repeated running and pounding on hard surfaces can result in
pediatric heel pain. Children and adolescents who take part in a lot of sport are especially vulnerable. Over-pronation (fallen arches and rolling inwards of the feet) will increase the impact on the
growth plate and is therefore a significant cause and a major contributing factor to heel pain in children.
Some of the common symptoms of Sever's disease are pain in one or both heels with running and walking. The pain is originates from the point of the heel where the tendo-achilles inserts into the heel
bone. Heel pain that goes away when resting. Swollen heel. Calf muscle stiffness first thing in the morning.
A physical exam of the heel will show tenderness over the back of the heel but not in the Achilles tendon or plantar fascia. There may be tightness in the calf muscle, which contributes to tension on
the heel. The tendons in the heel get stretched more in patients with flat feet. There is greater impact force on the heels of athletes with a high-arched, rigid foot. The doctor may order an x-ray
because x-rays can confirm how mature the growth center is and if there are other sources of heel pain, such as a stress fracture or bone cyst. However, x-rays are not necessary to diagnose Sever?s
disease, and it is not possible to make the diagnosis based on the x-ray alone.
Non Surgical Treatment
Treatment for Sever?s disease is mainly supportive, to stop inflammation and reduce pain. The condition will resolve on its own when the growth in the growth plate is complete, but until then,
measures can be taken to resolve pain and discomfort. Applying ice to the painful or swollen areas on the foot may provide some short-term relief from pain and prevent further inflammation. Ice can
be applied for about 20 minutes two or three times a day. Footwear that is too big, too small, or does not provide proper support can exacerbate the symptoms of Sever?s disease. Supportive footwear
is important to prevent discomfort, especially in children who participate in sports and activities that take place on a hard surface (such as pavement or a basketball court). Shoes should also have
adequate padding and not rub against the heel. In some cases, shoes that do not have heels (such as sandals) may be more comfortable to wear while the heel is healing, but care should be taken that
the shoe provides proper support to the rest of the foot. Children with Sever?s disease should avoid going barefoot.Children with flat feet, high arches, or over-pronation may need treatment to
resolve these underlying conditions. In many cases, an orthotic worn inside the shoe can help put the foot into a better alignment and provide relief to the foot or the arch. Children who are
overweight or obese may be counseled to lose weight. Being overweight can contribute to the development of several conditions, including Sever?s disease. Resting the foot and discontinuing sports and
other activities until the pain and stiffness is resolved may be recommended. In extreme cases, a walking boot or a cast might be used to completely immobilize the foot. A physical therapist may
recommend stretching exercises for the muscles in the calf and the Achilles tendon. A stretching routine is usually done several times a day. Stretching these muscles can help improve strength and
decrease the stress on the heel plate. Some physicians may recommend over-the-counter pain relievers such as ibuprofen or acetaminophen. Care must be taken when administering these medications to
children, especially with acetaminophen, as overdoses are possible when using more than one medication containing acetaminophen. Aspirin should never be given to children. The utility of pain
relievers in children must be weighed against their possible side effects. For small variations-less than an inch or so-shoe lifts can help equalize the length of the legs. In cases with more
variation between legs, surgical solutions may be considered. Research indicates that targeted manual therapy techniques performed by a licensed physical therapist can help to reduce pain from
Sever?s Disease and to improve muscle function. When the larger calf muscles and the smaller ankle and foot muscles become tight, this tightness can affect the mechanics of the ankle joint. Manual
therapy includes both joint and muscle release techniques to restore optimal function to the calf, ankle, and foot muscles, and results can generally be achieved within a few months.
The best way to prevent Sever's disease is to make sure that your child wears shoes that fit properly. The heel portion of the shoe should not be too tight, and there should be good padding in the
heel. It may help to put extra heel pads in your child's shoes. Some children simply get too much physical activity. For example, they may play on too many teams or practice for too long. Their heel
pain is a message to slow down.