Introduction
Background
Sever disease is a painful inflammation of the calcaneal apophysis. It is classified with the child and adolescent nonarticular osteochondroses.1,2,3,4 (The other disease in this group is Iselin disease, which is inflammation of the base of the fifth metatarsal.) The etiology of pain in Sever disease is believed to be repetitive trauma to the weaker structure of the apophysis, induced by the pull of the tendo Achilles on its insertion. This results in a clinical picture of heel pain in a growing active child, which worsens with activity.5,6,7,8,9,10,11,12
Sever disease. Lateral radiograph of foot in symptomatic 9-year-old male soccer player. Sclerosis is not diagnostic of Sever disease but is a characteristic radiographic finding.
Transverse MRI of foot in symptomatic 11-year-old girl with heel pain showing osteomyelitis. Pain was increased with activity but more constant and with more associated night pain than expected with Sever disease. Treatment included surgical debridement and antibiotic therapy.
Labeled MRI depicts the anatomy and mechanical forces responsible for the development of Sever disease (shear stress at the calcaneal apophysis).
In 1912, J.W. Sever, MD, first described this condition in the New York Medical Journal. He described it as an inflammation of the calcaneal apophysis resulting in the clinical symptoms of pain at the posterior heel, mild swelling, and difficulty with walking.13,14
Pathophysiology
The calcaneal apophysis develops as an independent center of ossification (possibly multiple). It appears in boys aged 9-10 years and fuses by age 17 years; it appears in girls at slightly younger ages. During the rapid growth surrounding puberty, the apophyseal line appears to be weakened further because of increased fragile calcified cartilage. Microfractures are believed to occur because of shear stress leading to the normal progression of fracture healing. This theory explains the clinical picture and the radiographic appearance of resorption, fragmentation, and increased sclerosis leading to eventual union. The radiographs showing fragmentation of the apophysis are not diagnostic because multiple centers of ossification may exist in the normal apophysis, as noted above. However, the degree of involvement that occurs in children displaying the clinical symptoms of Sever disease appears to be more pronounced.
Frequency
International
Although no exact figures of the occurrence of Sever disease exist, it is a relatively common problem in growing active children.
Mortality/Morbidity
Although no well-recognized, long-term sequelae of untreated Sever disease exist, Sever disease causes pain that can limit performance and participation in sports, and if left untreated, the pain can significantly limit even simple activities of daily life.
Sex
Incidence is higher in boys than in girls. Micheli and Ireland reported on 85 patients, 64% of whom were male.15
Age
Sever disease occurs most frequently in active 10- to 12-year-old boys. In Micheli and Ireland's report on 85 patients, the average age of presentation was 11 years 10 months for boys and 8 years 8 months for girls.15
Clinical
History
The typical clinical presentation is the active child (aged 9-10 y) who complains of pain at the posterior heel made worse by sports, especially those involving running or jumping. The onset is usually gradual. Often, the pain has been relieved somewhat with rest and, therefore, patiently monitored by the patient, parents, coaches, trainers, and family physicians, expecting it to resolve. When the pain continues to interfere with sports performance and then with daily activities, further consultation is sought.
Physical
Physical examination varies depending on the severity and length of involvement. Bilateral involvement is present in approximately 60% of cases. Most patients experience pain with deep palpation at the Achilles insertion and pain when performing active toe raises. Forced dorsiflexion of the ankle also proves uncomfortable and is relieved with passive equinus positioning. Swelling may be present but usually is mild. In long-standing cases, the child may have calcaneal enlargement.
Causes
Sever disease, like other similar conditions (eg, Osgood-Schlatter disease, little-leaguer's elbow, iliac apophysitis), is believed to be caused by decreased resistance to shear stress at the bone–growth plate interface. Studies have indicated that traction apophyses have a higher composition of fibrocartilage than epiphyses subjected more to axial load, which are composed predominantly of hyaline cartilage.
Labeled MRI depicts the anatomy and mechanical forces responsible for the development of Sever disease (shear stress at the calcaneal apophysis).
The anatomy of the calcaneal apophysis lends to significant shear stress because of its vertical orientation and the direction of pull from the strong gastrocsoleus muscle group (see Image 3).
More on Sever Disease |
 Overview: Sever Disease |
| Differential Diagnoses & Workup: Sever Disease |
| Treatment & Medication: Sever Disease |
| Follow-up: Sever Disease |
| Multimedia: Sever Disease |
| References |
| Further Reading |
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References
Pappas AM. The osteochondroses. Pediatr Clin North Am. Aug 1967;14(3):549-70. [Medline].
Katz JF. Nonarticular Osteochondroses. Clinical Orthopaedics and Related Research. 1981;158:70.
Pizzutillo PD, Sullivan JA, Grana WA. Osteochondroses, Chapter in The Pediatric Athlete, American Academy of Orthopaedic Surgeons Seminar, Oklahoma City Oklahoma, November 1998.
Roy DR. Accessory Navicular and Osteochodroses of the Foot and Ankle in the Child and Adolescent. Foot and Ankle Clinics. Philadelphia: WB Saunders;1998.
Scharfbillig RW, Jones S, Scutter SD. Sever's disease: what does the literature really tell us?. J Am Podiatr Med Assoc. May-Jun 2008;98(3):212-23. [Medline].
Lau LL, Mahadev A, Hui JH. Common lower limb sport-related overuse injuries in young athletes. Ann Acad Med Singapore. Apr 2008;37(4):315-9. [Medline].
Malanga GA, Ramirez-Del Toro JA. Common injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am. May 2008;19(2):347-71, ix. [Medline].
Weiner DS, Morscher M, Dicintio MS. Calcaneal apophysitis: simple diagnosis, simpler treatment. J Fam Pract. May 2007;56(5):352-5. [Medline].
Clemow C, Pope B, Woodall HE. Tools to speed your heel pain diagnosis. J Fam Pract. Nov 2008;57(11):714-23. [Medline].
Irving DB, Cook JL, Young MA, Menz HB. Impact of chronic plantar heel pain on health-related quality of life. J Am Podiatr Med Assoc. Jul-Aug 2008;98(4):283-9. [Medline].
Hendrix CL. Calcaneal apophysitis (Sever disease). Clin Podiatr Med Surg. Jan 2005;22(1):55-62, vi. [Medline].
Turek SL. Orthopaedics: Principles and Their Application. JB Lippincott Company:1984: 1474.
Sever JW. Apophysitis of the Os Calcis. New York Medical Journal. 1912;95:1025-1029.
Sever JW. Apophysitis of the Os Calcis. American Journal of Orthopaedics. 1917;15:659.
Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. Jan-Feb 1987;7(1):34-8. [Medline].
Brenner JS. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics. Jun 2007;119(6):1242-5. [Medline].
Further Reading
Related eMedicine topics
Plantar Heel Pain
Retrocalcaneal Bursitis
Athletic Foot Injuries
Overuse Injury
Limping Child
Clinical guideline
ACR Appropriateness Criteria® chronic foot pain.
Clinical trial
A Randomized Controlled Trial of Custom Foot Orthoses for the Treatment of Plantar Heel Pain
Keywords
Sever disease, Sever's disease, calcaneal apophysitis, calcaneal epiphysitis, traction apophysitis, Achilles tendon pain, heel pain
