eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Sever Disease: Treatment & Medication

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
Contributor Information and Disclosures

Updated: Apr 9, 2009

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.

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

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

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

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.

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

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

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

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

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

  1. Pappas AM. The osteochondroses. Pediatr Clin North Am. Aug 1967;14(3):549-70. [Medline].

  2. Katz JF. Nonarticular Osteochondroses. Clinical Orthopaedics and Related Research. 1981;158:70.

  3. Pizzutillo PD, Sullivan JA, Grana WA. Osteochondroses, Chapter in The Pediatric Athlete, American Academy of Orthopaedic Surgeons Seminar, Oklahoma City Oklahoma, November 1998.

  4. Roy DR. Accessory Navicular and Osteochodroses of the Foot and Ankle in the Child and Adolescent. Foot and Ankle Clinics. Philadelphia: WB Saunders;1998.

  5. 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].

  6. 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].

  7. 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].

  8. Weiner DS, Morscher M, Dicintio MS. Calcaneal apophysitis: simple diagnosis, simpler treatment. J Fam Pract. May 2007;56(5):352-5. [Medline].

  9. Clemow C, Pope B, Woodall HE. Tools to speed your heel pain diagnosis. J Fam Pract. Nov 2008;57(11):714-23. [Medline].

  10. 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].

  11. Hendrix CL. Calcaneal apophysitis (Sever disease). Clin Podiatr Med Surg. Jan 2005;22(1):55-62, vi. [Medline].

  12. Turek SL. Orthopaedics: Principles and Their Application. JB Lippincott Company:1984: 1474.

  13. Sever JW. Apophysitis of the Os Calcis. New York Medical Journal. 1912;95:1025-1029.

  14. Sever JW. Apophysitis of the Os Calcis. American Journal of Orthopaedics. 1917;15:659.

  15. 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].

  16. Brenner JS. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics. Jun 2007;119(6):1242-5. [Medline].

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Keywords

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

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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.

 
 
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