What is the diagnosis?

Sever’s disease or calcaneal apophysitis.

•  Pearl: Sever’s disease is the primary cause of heel pain in pediatric patients between the ages of 8-15, especially in those with obesity, high levels of physical activity, or experiencing rapid growth spurts [1]. It can also be seen when there is an increase in activity (such as increasing the number of games or frequency of practice).

• Pearl: Biomechanical factors including poor heel cord flexibility, pes cavus, pes planus, genu varum, or forefoot varus can predispose patients to Sever’s disease [2].

What is the mechanism of injury?

The exact mechanism of injury in Sever’s disease is unknown, however it is believed to be an overuse injury involving repetitive stress and pressure on the calcaneal growth plate from the pull of the Achilles tendon that results in inflammation on the unossified apophysis [3-4].

• Pearl: It frequently occurs before or during the peak of a growth spurt and shortly after a child begins a new sport.

What physical exam findings are expected?

On inspection, the heel may appear swollen near the Achilles insertion, however the exam should be negative for erythema or ecchymosis. Tenderness is usually present along the medial and lateral aspects of the heel. Range of motion should be normal, however there may be pain with passive ankle dorsiflexion. Pain may also be reproduced by standing on the tiptoes (Sever sign).

• Pearl: The squeeze test is the most common clinical test for diagnosis. A positive test elicits pain upon compression of the medial and lateral aspects of the heel.

Which imaging modality can be used?

Imaging is usually not necessary for diagnosis as it is a clinical diagnosis, however if the presentation is atypical or the pain is severe, a plain radiograph can be obtained to rule out fractures.

• Pearl: If obtaining radiographs, consider bilateral imaging to rule out normal variants (fragmentation, sclerosis, or increased density of the calcaneal apophysis) [2].

• Pearl: The differential for heel pain in the pediatric populations also includes plantar fasciitis, achilles tendonitis, stress fractures, tarsal coalition, juvenile arthritis, and pes planus.

Ultrasound can be used and may reveal fragmentation of the apophysis with a “saw tooth appearance” [5].

MRI is the most accurate imaging modality to assess damage of the epiphysis and may reveal edematous changes in the calcaneal apophysis [5].

What is the management in the ED? When do you consult Orthopedics?

The mainstay of treatment is rest and periods of inactivity to reduce the stress on the apophyseal region. Patients should be educated on the importance of not participating in sports until symptoms subside and that symptoms can recur until the bone fully matures and the apophysis closes. Symptoms typically improve within 6 to 12 months after reducing activity. Achilles tendon stretches, ice application, and NSAIDs can also be used. In the ED, offer pain control and discharge with orthopedic or sports medicine follow up. Emergent orthopedic consultation is not required.

• Pearl: if the patient continues to have pain, orthotics (like a CAM boot) or casting can be used to aid in immobilization.

What can patients expect with follow up in the outpatient setting?

Patients may return to play after appropriate rest and with return of range of motion and strength. However, preventive measures should still be taken both during and after the healing process to prevent re-injury or further complications, such as avulsion fractures. Patients should make efforts to wear supportive shoes with heel pads, heel lifts, or heel cups if needed. Athletic coaches should consider a variety of cross-training, endurance, and flexibility exercises to avoid overuse injuries from repetitive movements [6].