Sever's Disease

Definition

Sever's disease is a musculoskeletal condition that affects children and adolescents as they grow. Also called calcaneal apophysitis, it is a painful inflammation of the growth plate or epiphyseal plate, in the heel bone.

The term ‘disease’ is deceptive, simply put, it is a condition of the heel caused by overuse which affects adolescents during growth spurts in puberty. This is typically between eight and 13 for girls and 10 and 15 for boys. After this time, growth at the heel finishes, the bones at the heel fuse together and the inflammation subsides.

Inflammation can occur when the soft tissues connected to the heel mature more quickly than the bone itself, putting pressure on the bone. Pain is often experienced during adolescent and pre-pubescent growth spurts.

It is more common in active, athletic children and adolescents that play a lot of sport in school and outside, perhaps for a local or county team. Some sports are worse than others for exacerbating symptoms, for example, gymnastics in bare feet is typically bad. Running on tarmac or concrete at length is also likely to worsen the condition, as the heel bone is sensitive to repeated pounding into the pavement. Heel pain can be experienced in one or both feet.

Causes

Strenuous exercise, particularly sprinting, can often aggravate already over-stretched tendons and result in the onset of Sever’s.

In many cases of Sever's the biomechanics of the foot type may increase the chances of developing the disease. These are common foot types that can be causal:

  • a pronated foot type will cause tightness of the Achilles tendon, which increases the stress over the heel bone
  • a high arched foot can also cause tightness over the Achilles tendon
  • leg length discrepancy will cause uneven stress on the heel of the shorter leg
  • Anecdotally, we also see a lot of hypermobile children suffering from Sever’s

 

 

Symptoms

The external appearance of the heel is almost always normal and the primary symptom is a sharp pain that goes up one or both heels, usually at the back. Swelling, tenderness or a tight heel are also painful symptoms that a child may experience. At times the pain can be so debilitating that patients enter the clinic limping or walking on their tip-toes. Sudden knocks to the foot can also be very painful.

Other symptoms may include swelling or redness at the heel, difficulty walking, stiffness upon waking, and discomfort when the heel is squeezed at both sides.

Heel pain that gets worse during and after exercise, particularly jumping or running, can be an indication of Sever’s. There are no long-term consequences of getting the condition at any age.

 

Tests and Diagnosis

A diagnosis is made based on the symptoms. A ‘positive squeeze test’ is used by a GP or clinician as a diagnostic test, by squeezing the heel to bring on the pain. X-rays and imaging do not diagnose Sever's but they may be used to rule out other injuries such as fractures. 

 

Orthotic Treatments

Sever's disease is commonly treated by rest, anti-inflammatory pain relief, ice and elevation. Sometimes the pain will disappear within a few weeks or after a period of rest, but there is the potential for it to recur until the growth plate is fully developed.

When parents come into the clinic, one of the first things we often ask them to do, if their child is particularly active, fills out an activity timetable over a period of weeks to determine how much exercise they are doing and whether it could be considered too much whilst their muscles and skeleton matures.

The long-term prognosis is positive, as the condition is self-limiting i.e. a child will eventually grow out of it during puberty. However, the break from sport can be hard for children who enjoy playing regularly for a team at a competitive level. For cases like this, bespoke orthotic insoles can offer a good solution.

Foot orthotics can help all foot types with a predisposition to Sever’s, by normalising the foot posture, particularly the hindfoot and reducing stress at the heel caused by a tightened Achilles heel.

Heel lift orthotics raise the heel inside the shoe and can prevent the Achilles from pulling hard on the growth plate. For other patients, more padding or shock-absorbing material may be appropriate and added to their insoles. As they are bespoke, they will vary from patient to patient.

FAQs:

An AFO is an Ankle Foot Orthosis which as the name would suggest encompasses the ankle and foot. The objective is to control the position and movement of the ankle. AFOs are used to support weak limbs; they can also be used to immobilise the ankle and lower leg to correct foot drop. When set up correctly they can also have a great influence on the knee and hip joints. They are the most commonly used Orthoses.

The length of time that one needs to wear an AFO very much depends on the condition being treated. If it is a long-term condition like cerebral palsy or post-polio syndrome it is likely to be years as the condition cannot be cured. Your orthotist will advise you.

A patient’s comfort in their AFO is vital for compliance with the prescribed wearing regime.

So there are a number of steps the orthotist should take to ensure a comfortable fit: the patient’s heel should fit fully into the heel cup without excess space, the contours of the plantar surface of the AFO should match the patient’s foot, for children there needs to be up to half an inch growth room in the toe shelf length. At LOC we use our Gait Laboratories at our Kingston and Manchester clinics to fine-tune our bespoke orthotics.

A GRAFO is used to control instabilities in the lower limb by maintaining proper alignment of limbs and controlling their motion. It reaches around to the front of the knee extending down to the ankle. It works by altering a patient’s limb presentation to displace load and impact as well as offering further control to the knee.

The cost of an AFO is dependent on the type of AFO that has been prescribed and the material that it has been made with. Carbon fibre will be more expensive than metal or plastic for example. LOC’s bespoke AFOs cost can be found on our Orthotic Prices page.

The ability to drive while wearing an AFO is dependent on the condition being treated and the orthosis that has been prescribed. If wearing a hinged AFO, for example, you will be able to drive, but if wearing a knee brace, you won’t. Your orthotist will advise you.

The most flexible type of AFO is a Dynamic Ankle Foot Orthosis (DAFO).  It is thin and provides flexible support to the foot and ankle.

Both normal AFOs and DAFOs improve static balance (eg: while standing). Research among MS sufferers suggests that DAFOs aided balance while walking more than AFOs.

The simple answer is: yes they can. However one has to be sensible and look for wide-fitting trousers/jeans preferably of light and thin material.

Typically an AFO is stiff and rigid whereas a DAFO is thin, flexible and wraps around the patient’s entire foot. A DAFO provides support but also allows some range of normal movement.

A Supra Malleolar Orthosis SMO gets its name from the part of the body it encompasses. Thus an SMO supports the leg just above the ankle bone or malleoli. It allows dorsiflexion and plantar flexion(toes up and toes down) but eliminates mediolateral movement.

It typically takes a few weeks but is slightly dependent on the chosen materials and current availability.

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