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. [22, 23] When Sever disease (calcaneal apophysitis) occurs, the pain that the child experiences not only can limit performance and participation but also, if left untreated, 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. [17]
If the symptoms 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.
Perhamre et al, building on data showing that the use of insoles in Sever disease could reduce pain without necessitating limitation of physical activity, compared two insole types (heel wedge and heel cup) in 51 boys with this condition to determine which type was more effective for this purpose. [24] More than three quarters of the patients preferred the heel cup. All patients maintained a high level of physical activity throughout the study.
Use of custom-made foot orthoses may yield improved benefit as compared with use of "off-the-shelf" heel lifts. [25]
For severe cases, short-term (2-3 weeks) cast treatment in mild equinus can be used.
Although several studies have shown that heel inserts and prefabricated orthotics may initially improve pain scores and dysfunction, patients appear to have equal improvement by 3 months with or without therapy. [26]
Activity
Limitation of activity (especially running and jumping) usually is necessary (see Medical Care). Failure to instruct players, parents, coaches and trainers regarding limitation of activity and proper preexercise and postexercise stretching can lead to prolonged symptoms and further limitation of performance.
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 that they are able to initiate early protective measures and seek medical referral when necessary.
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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).
