History
The typical clinical presentation of calcaneal apophysitis (Sever disease) is an active child (aged 9-10 years) who complains of pain at the posterior heel [20] that is 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 consequently has been patiently monitored by the patient, parents, coaches, trainers, and family physicians, in the expectation that it will resolve. When the pain continues to interfere with sports performance and then with daily activities, further consultation is sought.
It should be kept in mind that 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.
Physical Examination
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.
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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.
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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.
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Labeled MRI depicts the anatomy and mechanical forces responsible for the development of Sever disease (shear stress at the calcaneal apophysis).
