Severs Disease

INTRODUCTION
Sever's disease or Calcaneal apophysitis is a condition that
affects children between the ages of 10 and 13 years. It is characterized
by pain in one or both heels with walking. During this phase of life,
growth of the bone is taking place at a faster rate than the tendons.
Hence there is a relative shortening of the heel-cord compared to the
leg bones.
As a result, the tension the heel-cord applies to the heel bone at
its insertion is very great. Moreover, the heel cord is attached to
a portion of the calcaneus (heel bone) that is still immature, consisting
of a mixture of bone and growing cartilage, called the calcaneal apophysis,
which is prone to injury. Compounding to this is the fact that all these
changes are happening in a very active child, prone to overuse. The
end result is therefore an overuse syndrome of injury and inflammation
at the heel where the heel cord (Achilles Tendonitis) inserts into the
heel bone (Calcaneal apophysitis).
SYMPTOMS
The typical patient is a child between 10 and 13 years of age, complaining
of pain in one or both heels with running and walking. The pain is localized
to the point of the heel where the tendo-achilles inserts into the calcaneus
(heel bone), and is tender to deep pressure at that site. Walking on
his toes relieves the pain.
CAUSES
The actual pathology of the condition is one of more of an overuse
syndrome in which the growth plate of the heel may become slightly displaced,
causing pain. Biopsies of similar conditions have shown changes consistent
with separation of the cartilage.
The cause of Sever's disease is not entirely clear. It is most likely
due to overuse or repeated minor trauma that happens in a lot of sporting
activities - the cartilage join between the two parts of the bone can
not take all the shear stress of the activities. Some children seem
to be just more prone to it for an unknown reason - combine this with
sport, especially if its on a hard surface and the risk of getting it
increases.
A pronated foot
is one of the most common contributing factors. Over pronation is a
biomechanical condition of the foot which involves a rolling outward
of the foot at the ankle, so that when walking the inner side of the
heel and foot bears more of the body's weight than is normal.
This causes a shortening or tightening of the achilles tendon and
increases the force of its pull on the heel's growth plate thus causing
severs disease. Orthotics such as the Dr Foot Pro are essential for
children that over pronate.
Most cases of Sever's Disease show findings of equinus
(tightness or loss of flexibility), of the calf muscle. Equinus is the
single most important mechanical loading issue in Sever's Disease. Therefore
it is imperative that we stretch the calf muscle.
The amount of equinus a child experiences can be determined by measuring
the range of motion of the ankle with the knee flexed and extended.
When the knee is flexed, the amount of equinus of the calf muscle is
measured. The podiatrist will extended the knee and measure both the
soleus and gastrocnemius muscles (the two muscles that comprise the
term calf muscle). Normal range of motion of the ankle in a normal gait
(walking) cycle is 10 to 15 degrees beyond 90 degrees. This means that
the normal range requires the ankle to dorsiflex (pushing the foot upwards)
to 90 degrees plus an additional 10 to 15 degrees. An inability to complete
this range of motion is termed equinus.
Other causes include a short achilles tendon which causes a pull of
the achilles tendon on the heel's growth plate causing inflammation
and pain.
If one leg is shorter than than the other the shorter leg tends to
plantar flex more (push down) which pulls on the achilles tendon and
can causes severs heel.
Flat or high arches can be a contributing factor. Both of these conditions
causes the heel not to be positioned normally within the foot due to
the height of the arch. Thus leads to the achilles tendon's attachment
to the heel being affected. Abnormal arch height may contribute to the
onset of Sever's Disease which is why orthotics as essential for children
suffering with severs heel that have flat or high arches.
The condition is very similar to Osgood-Schlatters
Disease which occurs at the knee.
WHAT YOU SHOULD
DO
- Help an overweight child lose weight.
- Encourage your child to exercise moderately, avoiding extremes.
WHAT YOU SHOULD
NOT DO
- Ignore the pain.
You can not grow out of this disease!
TREATMENT
Treatment revolves around decreasing activity. Usual treatment has
been putting children in a boot in slight equinus, or a cast with the
foot in slight equinus, thereby decreasing the tension on the heel cord,
which in turn pulls on the growth plate at the heel. As the pain resolves,
children are allowed to go back to full activities.
- The use of an ice pack after activity for 20mins is often useful
for calcaneal apophysitis - this should be repeated 2 to 3 times a
day.
- If the symptoms are bad enough and are not responding to these measures,
medication to help with inflammation may be needed. In some cases
the lower limb may need to be put in a cast or fiberglass cast with
a heel lift for 2-6 weeks to give it a good chance to heal.
- Calf stretches 6/day for 60 seconds each. Calf stretches are best
accomplished by standing with the toes on the edge of a stretching
block. Or you could use the pro stretch below.
LONG TERM
IMPLICATIONS
This condition is self limiting - it will go away when the two parts
of bony growth join together - this is natural. Unfortunately, Sever's
disease can be very painful and limit sport activity of the child while
waiting for it to go away, so treatment is often advised to help relieve
it. In a few cases of Sever's disease, the treatment is not successful
and these children will be restricted in their activity levels until
the two growth areas join - usually around the age of 16 years. There
are no known long term complications associated with Sever's disease.
Recommended Products

Orthotic shoe inserts are a good way to treat the symptoms,
as well as help eliminate Severs Disease completely. Orthotic devices
such as the Dr Foot Pro Insoles have had great clinical success in treating
children who suffer from Severs Disease.
Click
here to view orthotics

Most cases of Sever's Disease show findings of tightness
of the calf muscle. The pro stretch enables the child to stretch not
only the calf muscles but also the achilles tendon and the plantar fascia.
Three 30-second step stretches work wonders for heel pain.
Click
here to view the pro stretch

Podiatrists recommend the use of heel cushions for improved
shock absorption and support and to limit the movement of the severe's
heel. They will help to cushion and protect the heel each time your
child takes a step. Also, because of the thickness of the heel cushion,
the heel is slightly raised, which will help to reduce the pull of the
Achilles Tendon on the tender and inflamed growth plate.
Click
here to view the heel cushions

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