Posterior Calcaneal apophysitis, also known as Sever disease, is the painful inflammation of the apophysis of the calcaneus. It typically presents in active young children and adolescents, especially those who enjoy jumping and running sports. High plantar foot pressures are associated with Sever disease, although it is unclear whether they are a predisposing factor or a result of the condition. Gastrocnemius equinus may be a predisposing factor for Sever disease.
General
- Seen in skeletally immature athletes
- Traction at the Achilles Tendon insertion site correcting with the secondary ossification center
- Occurs with growth spurts, increased activity, or repetitive running and jumping
- Presents as heel pain secondary to overuse
- Resolves with skeletal maturation and closure of apophysis
Causes
- Repetitive strain and microtrauma
- Caused by force of the Achilles tendon which inserts at secondary ossification center
- Results in irritation and potential partial avulsion of the calcaneal apophysis
- Sports
- Running and jumping sports
- Basketball
- Soccer
- Gymnastics
- Extrinsic
- Long or year-round activities
- Poorly fitting or worn-out footwear
- Poor training mechanics
- Intrinsic
- Poor heel cord flexibility
- pes cavus
- pes planus
- genu varum
- forefoot varus
Differential Diagnosis
- Fractures & Dislocations
- Distal Tibia Fracture
- Distal Fibular Fracture
- Talus Fracture
- Calcaneus Fracture
- Subtalar Dislocation
- Ankle Fracture (& Dislocation)
- Peroneal Subluxation
- Muscle and Tendon Injuries
- Peroneal Tendon Injuries
- Achilles Tendonitis
- Achilles Tendon Rupture
- Posterior Tibial Tendon Dysfunction
- Flexor Hallucis Longus Tendinopathy
- Ligament Injuries
- Lateral Ankle Sprain
- Medial Ankle Sprain
- Syndesmotic Sprain
- Chronic Ankle Instability
- Intersection Syndrome Foot
- Bursopathies
- Retrocalcaneal Bursitis
- Nerve Injuries
- Peroneal Nerve Injury
- Tarsal Tunnel Syndrome
- Arthropathies
- Osteoarthritis of the Ankle
- Osteochondral Defect Talus
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin’s Disease)
- Calcaneal Apophysitis (Sever’s Disease)
- Other
- Haglunds Deformity
- Posterior Ankle Impingement Syndrome
- Sinus Tarsi Syndrome
Diagnosis
- History
- Children are typically 8 to 14 years old
- Pain over the calcaneal apophysis/calcaneal insertion of Achilles tendon
- Pain with activity or impact, worse on hard surfaces, wearing cleats
- Resolution of pain with rest
- Limping may be present
- Physical Exam: Physical Exam Ankle
- May have erythema, swelling, warmth
- Tender over achilles tendon insertion
- Pain with passive ankle dorsiflexion
- Tight Achilles tendon and calf muscles
- Pes planus or pronated forefoot may be present
- Special Tests
- Squeeze Test: Pain over the posterior calcaneus with compression)
- Sever Sign: Increased pain at calcaneus with standing on tiptoes
- Clinical diagnosis and imaging is not routinely required
Radiographs
- Standard Radiographs Ankle or Standard Radiographs Foot
- Typically normal, especially early in disease process
- Rule out other pathology including fractures, osteomyelitis, bone cysts
- Potential findings
- Sclerosis may be present
- Fragmentation is frequently present
MRI
- Findings
- Localize inflammation to apophysis
- Evaluate for other pathologies stress fracture, lytic lesions, osteomyelitis
Treatment
- Indications
- All patients
- Activity modification/Rest
- Discontinue offending activity
- Physical Therapy
- Achilles tendon stretches, hamstring stretches
- Strengthening of dorsiflexors
- Heel pads/cups
- Insertion can offload some tenson on achilles
- Immobilization in severe cases
- Either Tall Walking Boot or Tall Walking Cast
- May require non weight bearing status
- Other
- Ice
- NSAIDS
- Establish proper footwear
- Prevention
- Maintain calf flexibility and ankle dorsiflexion
- Limit use of cleats or time on hard surfaces
Operative
- Indications
- No role for operative treatment
