Patient Background and Relevant History
Age: 9 years old
Gender: Male
Activity: Soccer
Site of pain: The back of both heels
Clinical presentation and observations:
- Tenderness on palpation of both posterior heels at the Achilles tendon insertion on the back of the calcaneus (heel bone)
- Pain is worse with increase activity.
- The parent reports patient frequently limps off the court after a competitive match and is sore for days after.
- Tightness in the Achilles tendon and calf muscles and consequently reduced dorsiflexion ( the movement when you draw your toes back toward your shins) at the ankle joint.
Clinical Diagnosis: Sever's Disease.
Definition: Sever's Disease is defined as an "Apophyseal Osteochondroses" of the calcaneus.
There are several conditions defined as Apophyseal Osteochondroses, each one affecting different parts of the body. The common feature to them all is all these types of overuse injuries involve the growth plates of the bones and usually a traction injury involving a tendon.
The inclusion of the word "disease" in the name of this condition can cause some unnecessary concerns for parents and pediatric patients.
One of the most important things about most of these Osteochondroses is that they are almost always self-limiting. Meaning that they resolve when the involved bone's growth plate closes or is fully ossified (growth plate fuses with the main body of the bone). Sometimes however this can take several years and can cause a lot of discomforts and potential damage to the growing bones if left untreated.
Sever's Disease is a very common injury I see in the clinic in the pediatric athlete.
Sever's Disease Statistics
- Commonly presents in children aged 7-15 years
- more common in boys than girls
- It commonly occurs before or during a growth spurt during times of increased load from competitive sport.
- and approx 60% of cases are bilateral (both sides)
- It accounts for 8% of overuse injuries.
- Whilst it was commonly accepted that this condition was a result of traction injury, new evidence suggests that it is more likely to be a result of repetitive compression forces that damage and remodel bone itself.
Treatment Plan:
For this young athlete addressing his poor foot mechanics, footwear, and muscles tightness were key components of reducing his symptoms and helping him continue to play the sport that he loves so much.
Initially, I introduced a gel heel raise to temporarily reduce strain and impact on the back of the heel. This only produced a mild reduction in symptoms.
The addition of orthotic therapy to properly address poor alignment issues and footwear modification made a huge difference to his symptoms.
I prescribed a stretching and strengthening program over the course of a 12 week period to improve his eccentric muscle tightness and weakness.
Generally, pediatric patients find this part challenging and tedious, and keeping them engaged and on track can be one of the biggest challenges as a practitioner. I found using an online digital platform like Physitrack greatly improves patient engagement and adherence and ultimately results. The patient was able to see a video of the exercises he was to perform and record his progress daily.
We also incorporated some gait retraining during running and walking and focused on reducing Cadence (the number of steps per minute) and thus increasing stride length.
After 6 weeks....
The patent was able to play a full game of soccer without pain and even compete in consecutive competitive matches. His team made it to the semi-finals where they, unfortunately, lost (this time). He is keen for Covid restrictions to end, and for him and his team to have another go at winning the finals.
Take away message:
Overuse injuries in athletic children are common.
Reoccurring pain should be investigated.
Sever's Disease usually resolves when the heel bone fully ossifies (by age 15)
Podiatry treatment in the meantime can significantly reduce painful symptoms and necessary damage to the growing bone.