Sever’s Disease in Children
By: Michael Zapf, DPM
Richard and Rachel are twins who share a lot in life, including Sever’s disease. Before I go any further, I want to say that this condition is one of the most poorly named in all of medicine. It’s a condition of young athletes that lasts for a year or two and never has any serious consequences. It does not deserve the name “disease”. In my office I always refer to it as Sever’s condition and never use the “D” word. For the rest of this article I will refer it as Sever’s or Sever’s condition.
Now, let’s get back to our twins. They are 11 years old and play a variety of sports. Rachel does soccer, softball and dance while Richard’s favorites are soccer, lacrosse and tennis. They both presented to my office this year, Rachel in January and Richard just last week with pain in the back and bottom of their heels. The pain is aggravated by activities and gets so painful that they noticeably limp.
The condition affects both boys and girls during early adolescence. The age range is typically 7-15 years old for boys and 5-13 years old for girls. It is no coincidence that this is the age where the growth plates close. Severs condition is related to the growth plate- like structure on the back of the heel called the apophysis. In the picture that accompanies this description, the apophysis is the rather white crescent-shaped bone just below the arrow. The arrow, itself, is pointing at the union of the apophysis with the main part of the heel bone. At this point they look like separate bones but they are not. The black band, where the arrow is pointing, will soon fill in with bone and the problem will be over. Until then, the pain can be excruciating.
Two factors that always seem to accompany Severs condition are tight Achilles tendons and aggressive athletic activities. The third component that sometimes plays role is pronation or flattening of the foot.
When I entered podiatric medical school there were still some textbooks that said that Sever’s condition is mostly a problem of boys. That is clearly no longer true. Now that the girls are equally active in sports they are equally eligible to develop Sever’s condition. Since activity level plays a role in the level of pain these children have, so does reducing activities play a role in lessening the pain. Parents, coaches and physical education teachers need to be aware that they may have to reduce the heavy athletic schedule of these student athletes to get a handle on the pain. There is no way, just by looking, that parents and coaches can tell when the heel is hurting – we have to take the word of the child/patient.
The Achilles tendon attaches to the apophysis, which is the area of the bone below the arrow. If the Achilles tendon is very tight, and it almost always is in patients with Sever’s, it can cause a rapid ballistic pull on the apophysis increasing the pain. In the office we will test for a tight Achilles tendon. If it is tight we will usually recommend relaxing the pull of the tendon by wearing shoes with a heel or placing a heel lift in athletic shoes and cleats. Heel stretching exercises can also be beneficial but it is usually very difficult to get these young athletes to do it as aggressively and as frequently as it needs to be done. Sometimes we resort to a splint that stretches the Achilles tendon for several hours at a time.
Sometimes pronation, or flattening of the feet, has a significant role in the creation and prolongation of the pain of Severs condition. When it does, we can often decrease the level of pain with either over-the-counter or custom shoe inserts called orthotics. We can test for the ability of functional orthotics to reduce the pain by placing tape on the foot in a particular way to take this stretch off of the plantar fascia. Simply put, if the tape strapping makes the child less painful, so will an orthotic.
The application of ice to the heel is always a helpful aid in treating Sever’s condition. This can be done in a variety of ways but we recommend that it be done after athletic activities, before bed and any time that the child is complaining of heel pain.
The use of a non-steroidal medicine like aspirin and Motrin is controversial. I agree that it can be useful to decrease the pain and inflammation of Sever’s after athletic activities, but I oppose using these medications to allow the student athlete to play athletics more aggressively.
About twice a year we see a patient who has Sever’s pain so severe that the steps above do not provide enough relief. These children are in so much pain that they, sometimes, are not even able to walk to class. These cases usually require a fiberglass cast be placed on the leg and foot. The cast decreases activity so much that healing can now outpace injury. The cast is only needed for two or three weeks but sometimes it is the difference between the agony and the feet.
The good news for Richard and Rachel is that, no matter what they do, they will get older and more mature and the apophysis will close, eliminating their pain.
Treatment wise, Richard responded to the initial steps of decreasing some of his more aggressive back to activities, the use of heel lifts, regular stretching and ice therapy. Rachel still had pain with these measures but received significant relieved when we added functional orthotics to her regimen. Both have continued to be very active and should be completely out of pain in about a year and, certainly, by the time they reach high school.