Sever Disease

Sever disease is calcaneal apophysitis, an overuse injury of the growth plate at the back of the heel and the commonest cause of heel pain in active children. It is self-limiting and resolves when the calcaneal apophysis fuses.

It affects children aged 8 to 14 years, with a peak at about 10 to 12 years, and boys somewhat more than girls. It is bilateral in about 60%. Risk factors are running and jumping sports, a tight gastrocnemius soleus complex, high body mass, flat or high arched feet and hard surfaces.

Symptoms commonly last weeks to months, and recurrence is possible until skeletal maturity.

Pathophysiology.

Repetitive traction of the Achilles tendon on the unfused calcaneal apophysis, with a rapid growth spurt and tight calf muscles, causes microtrauma and inflammation of the physis.

The apophysis is weaker than the adjacent tendon and bone, so stress concentrates there.

• Activity related heel pain, worse after running and jumping and improved by rest, sometimes with a limp or toe walking.
• Tenderness over the posterior and plantar calcaneus, positive medial and lateral heel squeeze test, and tight calf muscles with reduced ankle dorsiflexion.
• No swelling, erythema or night pain in typical disease.

Red flags.

• Night pain, rest pain, fever, or systemic features.
• Unilateral symptoms with swelling, deformity, or a history of significant trauma.
• Age under 8 years or over 15 years, or symptoms lasting over several months.

• Clinical diagnosis from the history and examination. Imaging is not needed in typical cases.
• Radiographs show a sclerotic or fragmented apophysis, which also occurs in normal children and does not confirm diagnosis. Obtain them when symptoms are atypical, to exclude fracture, cyst, tumour or infection.
• Ultrasound or MRI, and blood tests (CRP, ESR), if infection, inflammatory arthritis or a bone lesion is suspected.

Differential diagnosis. Achilles tendinopathy, retrocalcaneal bursitis, calcaneal stress fracture, plantar fasciitis, osteomyelitis, bone cyst or tumour, enthesitis from juvenile idiopathic arthritis, tarsal coalition and Haglund deformity.

• Activity modification with relative rest from the aggravating sport, rather than complete rest, until pain settles, and then a graded return.
• Heel cushions or cups in shoes, stretching of the gastrocnemius soleus complex and strengthening, ice for 10 to 15 minutes after activity.
• Ibuprofen 5 to 10 mg/kg orally every 8 hours for a short course of 3 to 5 days for pain, or paracetamol 15 mg/kg every 4 to 6 hours.
• Short period of immobilisation in a walking boot or cast for 2 to 4 weeks for severe pain.
• Most children improve within 2 to 8 weeks, and almost all within 12 months.

Monitoring. Review at 4 to 6 weeks for response.

Referral and escalation. Refer to orthopaedics or sports medicine if symptoms persist over 3 months, for atypical features, or for any red flag.