eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Sever Disease

Updated: Apr 9, 2009

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).

Differential Diagnoses

Achilles Tendon Pathology
Calcaneus Fractures
Non-neoplastic Conditions Simulating Bone Tumors
Osteomyelitis
Tarsal Coalition

Workup

Imaging Studies

Radiograph findings include increased sclerosis and fragmentation of the calcaneal apophysis. However, it should be stressed that these findings are nonspecific and also are observed in asymptomatic feet (see Image 1). Radiographic evaluation is beneficial to exclude fracture or rare tumor. Remember that radiographic changes on plain x-ray films are neither diagnostic nor prognostic; they are beneficial to exclude other causes of heel pain. Explain this to patients and parents.

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.

Remember that if pain continues, becomes significant at rest, awakens the patient from sleep, or is associated with significant swelling, tests should be performed to look for other causes. Tarsal coalition is another hindfoot disorder that must be distinguished from Sever disease. Thus, if reduction of subtalar motion is found on physical examination, a CT scan can be helpful in differentiating this disease from failure of the bones of the hindfoot to separate.
In cases of high suspicion, MRI may be of use to rule out osteomyelitis (see Image 2).

Histologic Findings

Sever disease is characterized by disorder of the normal process of enchondral ossification.

Treatment

Medical Care

As children become involved in sports at younger ages and compete at higher levels and as expectations of the participants, parents, and coaches increase, incidence of overuse syndromes increases in growing athletes.¹⁶ When Sever disease occurs, not only does the child experience pain that can limit performance and participation but, if left untreated, the pain can significantly limit even simple activities of daily life. This raises concern in all persons involved. Although no well-recognized, long-term sequelae of untreated Sever disease exist, the physician's role is to minimize pain and allow the child to return to normal activities as soon as possible to enhance psychosocial development. The physician also must be able to differentiate Sever disease from other causes of heel pain in the child that are potentially more serious, such as tumor or osteomyelitis.

Treatment is initially focused on reducing the present pain and limitations and then on preventing recurrence. Limitation of activity (especially running and jumping) usually is necessary. In Micheli and Ireland's study, 84% of 85 patients were able to resume sports activities after 2 months.¹⁵
In patients with symptoms that are not severe enough to warrant limiting sports activities or if the patient and parents are unwilling to miss a critical portion of the sport season, wearing a half-inch inner-shoe heel lift (at all times during ambulation), a monitored stretching program, presport and postsport icing, and judicious use of anti-inflammatory agents normally reduce the symptoms and allow continued participation. If symptoms worsen, activity modification must be included.
In severe cases, short-term (2-3 wk) cast treatment in mild equinus can be used.

Activity

Limitation of activity (especially running and jumping) usually is necessary (see Treatment, Medical Care).

Medication

Judicious use of anti-inflammatory agents may be helpful for patients wishing to avoid limiting their sports activities (see Treatment, Medical Care).

Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Ibuprofen (Motrin, Ibuprin, Excedrin IB, Advil)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<12 years: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Naproxen (Naprosyn, Naprelan, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Follow-up

Deterrence/Prevention:

To prevent recurrence, patients, parents, coaches, and trainers should be instructed regarding a good preexercise stretching program for the child. Early in the season, encouragement should be given for a preseason conditioning and stretching program. Coaches and trainers should be educated about recognition of the clinical symptoms so they are able to initiate early protective measures and seek medical referral when necessary.

Complications:

No known complication exists from failure to make the correct diagnosis because the disease is self-limited.

Prognosis:

Sever disease is a self-limited condition.

Patient Education:

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center.

Miscellaneous

Medicolegal Pitfalls

Failure to instruct players, parents, coaches and trainers regarding limiting the patient's activity and proper preexercise and postexercise stretching can lead to prolonged symptoms and further limitation of performance.
Failure to instruct patients and parents that continual pain, significant swelling or redness, and fever are not signs of Sever disease and, therefore, require further evaluation could result in failure to diagnose a condition with much more serious long-term consequences.

Multimedia

Media file 1: 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.

Media file 2: 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.

Media file 3: Labeled MRI depicts the anatomy and mechanical forces responsible for the development of Sever disease (shear stress at the calcaneal apophysis).

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].

Keywords

Sever disease, Sever's disease, calcaneal apophysitis, calcaneal epiphysitis, traction apophysitis, Achilles tendon pain, heel pain

Contributor Information and Disclosures

Author

Mark A Noffsinger, MD, Clinical Instructor, Department of Orthopedic Surgery, Michigan State College of Human Medicine; Medical Director, Deptartment of Orthopedic Surgery, Bronson Methodist Hospital, Consulting Staff, Kalamazoo Orthopedic Clinic
Mark A Noffsinger, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Orthopaedic Medicine, American College of Physician Executives, American Fracture Association, American Medical Association, American Medical Directors Association, Christian Medical & Dental Society, Indiana State Medical Association, International Society on Thrombosis and Haemostasis, Michigan State Medical Society, Mid-America Orthopaedic Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida
James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

Further Reading

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Overuse Injury

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ACR Appropriateness Criteria® chronic foot pain.

Clinical trial

A Randomized Controlled Trial of Custom Foot Orthoses for the Treatment of Plantar Heel Pain