Does your child have heel pain? It could be Sever's disease.

Sever's disease (aka calcaneal apophysitis) sounds scary, but it is actually a common disorder in growing children that results in heel pain. The name is rather frightening, and the condition can be very painful, but the good news is that the prognosis is usually very good. This is especially true if your child receives appropriate care. Fortunately, many children respond quickly to proper physical therapy interventions.

 

What Causes this condition?

Unlike some causes of heel pain, Sever's disease is a tension condition not a compression disorder. Even though it is called a disease, it is not contagious; it is an acquired heel injury related to growing children.

Yes, “growing pains” are real and can occur following “growth spurts”. When the bones of the lower limb (e.g., tibia bone) grow faster than the calf muscles (e.g. Gastrocnemius and Soleus muscles) the calcaneal growth plate can be aggravated.

When you walk and run you flex forward at the ankle (dorsiflexion). The shortened calf muscles get tight prematurely during this motion and pull aggressively on your heel bone (calcaneus). Over time these traction forces from the tight calf muscles cause pain, swelling, and tenderness at the growth plate on the backside of the calcaneus (heel) bone. This painful heel condition typically occurs in girls between the age of 8-13 years of age and boys between 10-15 years of age.

Common Symptom's of Sever's Disease

  • Children with Sever’s disease commonly have pain, swelling and even redness of one or both heels.
  • Tenderness occurs at the heel and where the heel cord (the Achilles tendon) attaches to the calcaneus bone.
  • Tightness of the calf muscles and tendon.
  • Heel pain worse in the morning and after a prolonged rest but can also be aggravated by running and jumping.
  • Rest relieves the symptoms.
  • Gait deviations such as limping while walking or the heels coming off of the ground early while walking. Some children will even walk or run on their toes and forefoot (“tippy toe walking”). 

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Risk Factors

  • Pronated feet (low arches) can affect the alignment and tension on the Achilles tendon and calcaneus bone interface.
  • Pes Cavus (high arches) can also affect the alignment and tension on the Achilles tendon and calcaneus bone interface.
  • Being overweight can increase stressful forces.
  • Poor foot positioning during certain activities such as walking, running, or jumping can increase your child’s risk of developing this condition.
  • Being active is a risk factor. Children that play sports are exposed to activities that produce high-tension loads to your child’s heels, especially if the sport involves running and jumping on hard surfaces.
  • This disorder is more common in boys than girls.
  • Wearing stiff, hard shoes (e.g., soccer cleats).
  • There is a greater risk of acquiring this condition at the beginning of the sports season. 

How is Sever’s disease treated?

Your physical therapist at Redlands Physical Therapy will perform the best treatment interventions to optimize your child’s healing. We will also focus on preventing reoccurrences of this painful and disabling condition. The techniques employed at Redlands Physical Therapy are shown by research to reduce pain, increase function, and improve outcomes.

These interventions include:

  • Joint mobilization. Tightness within the ankle joint and foot joints limits ankle flexion (dorsiflexion) resulting in considerable increases in tension to the calf/heel interface. Gentle, skilled joint mobilization can restore normal ankle and foot joint mobility.
  • Soft tissue mobilization. We perform deep tissue release techniques to the posterior calf muscle and plantar fascia (on the sole of the foot) to increase flexibility and minimize tension to the heel. Manual deep tissue work combined with myofascial release, trigger point release, and instrument assisted soft tissue mobilization (IASTM) with movement greatly will increase flexibility reducing stressors to the heel.
  • Manual stretching and passive range of motion to the heel cord and plantar fascia.
  • Strengthening exercises to the stabilizing intrinsic foot muscles.
  • Stretching of the gastrocsoleus complex (calf) muscles.
  • Proprioception/balance training.
  • Gait training. We will help your child return to restore optimal walking and running biomechanics.
  • Taping and shoe inserts. If necessary we can fabricate a customized orthotic; however, this is not always required.
  • Modalities to reduce pain and swelling as well as promote healing.
  • Return to function and sports. We will work with your child to maximize movement patterns to restore normal, functional weight bearing activities; progressing towards pain free return to sports.
  • Home program & patient education. Your child will receive a customized home stretching and strengthening program to perform on the days that they are not in physical therapy to help maximize outcomes. He/she will also receive patient education related to this disorder.

Most children require 6-12 physical therapy sessions over a 2-4 week period to realize pain relief and restoration of function. At Redlands Physical Therapy we offer a 3 has rehabilitation program lasting 6 weeks. The first two weeks of the program are performed at home, and the last four weeks are performed in our clinic by a state licensed Doctor of Physical Therapy (DPT).

Other Recommendations

  • Application of cold packs to relieve pain and reduce swelling.
  • Shoe inserts to control foot pronation.
  • Heel lift to reduce tension on the Achilles tendon resulting in less stress to the heel.
  • Supportive, shock absorbing shoes with higher heels (good arch supports and higher heel-toe drop/offset/differential).
  • Relative rest or a reduction/modification of physical activities.
  • Your physician may also recommend prescription or over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation (e.g., naproxen or ibuprofen).

Prevention

The good news is that this condition is typically not long-term; however, it can continue to return until your child stops growing and their growth plates have fused.  Below are a few ways to prevent a reoccurrence:

  • Muscle flexibility. Stretching of calf muscles.
  • Proper shoe wear. Supportive shoes with adequate shock absorption.
  • Avoid over-training. Build up gradually for the sports season; avoiding large increases in training volume and over-training.
  • Adequate rest. Some children play sports, train for sports, are active on the play ground at school and involved in weight bearing activities after school. Even though being physically active is a healthy lifestyle, it can have an accumulative effect resulting in prolonged periods of rest without adequate periods of rest.
  • Weight loss. If your child is overweight, losing even few pounds can reduce the stresses to the heel.

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