Pediatric case studies, Apohisitis:

Calcaneal Apophysitis (Sever's Disease) What Is Calcaneal Apophysitis? Calcaneal apophysitis is a painful inflammation of the heel’s growth plate. It typically affects children between the ages of 8 and 14 years old, because the heel bone (calcaneus) is not fully developed until at least age 14. Until then, new bone is forming at the growth plate (physis), a weak area located at the back of the heel. When there is too much repetitive stress on the growth plate, inflammation can develop.

Calcaneal apophysitis is also called Sever’s disease, although it is not a true “disease.” It is the most common cause of heel pain in children, and can occur in one or both feet.

Heel Pain graph pain in children differs from the most common type of heel pain experienced by adults. While heel pain in adults usually subsides after a period of walking, pediatric heel pain generally doesn’t improve in this manner. In fact, walking typically makes the pain worse.

Causes Overuse and stress on the heel bone through participation in sports is a major cause of calcaneal apophysitis. The heel’s growth plate is sensitive to repeated running and pounding on hard surfaces, resulting in muscle strain and inflamed tissue. For this reason, children and adolescents involved in soccer, track, or basketball are especially vulnerable.

Other potential causes of calcaneal apophysitis include obesity, a tight Achilles tendon, and biomechanical problems such as flatfoot or a high-arched foot.

Symptoms Symptoms of calcaneal apophysitis may include:
• Pain in the back or bottom of the heel
• Limping
• Walking on toes
• Difficulty running, jumping, or participating in usual activities or sports
• Pain when the sides of the heel are squeezed

Diagnosis To diagnose the cause of the child’s heel pain and rule out other more serious conditions, the foot and ankle surgeon obtains a thorough medical history and asks questions about recent activities. The surgeon will also examine the child’s foot and leg. X-rays are often used to evaluate the condition. Other advanced imaging studies and laboratory tests may also be ordered.


The surgeon may select one or more of the following options to treat calcaneal apophysitis:
• Reduce activity. The child needs to reduce or stop any activity that causes pain.
• Support the heel. Temporary shoe inserts or custom orthotic devices may provide support for the heel.
• Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
• Physical therapy. Stretching or physical therapy modalities are sometimes used to promote healing of the inflamed issue.
• Immobilization. In some severe cases of pediatric heel pain, a cast may be used to promote healing while keeping the foot and ankle totally immobile.

Often heel pain in children returns after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of calcaneal apophysitis, or it may indicate a different problem. If your child has a repeat bout of heel pain, be sure to make an appointment with your foot and ankle surgeon.

Can Calcaneal Apophysitis Be Prevented? The chances of a child developing heel pain can be reduced by:
• Avoiding obesity
• Choosing well-constructed, supportive shoes that are appropriate for the child’s activity • Avoiding or limiting wearing of cleated athletic shoes Avoiding activity beyond a child’s ability.
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Common Overuse Injuries in Children Sever's Disease Sever's disease is one of most common causes of heel pain in children, and often occurs during adolescence when children hit a growth spurt. Also known as an osteochondrosis or apophysitis, Sever's disease is an inflammatory condition of the growth plate in the heel bone (calcaneus). Running, jumping, and being active lead to repetitive stress on the growth plate as the foot strikes the ground. This results in inflammation (swelling) in the growth plate which causes heel pain.

The primary treatment of Sever's disease is to rest the foot (stop the sport) until the pain goes away. Once the pain is gone, the child may return to normal activities.

Additional treatments may include:
• Heel pads. Heel cushions inserted in sports shoes can help absorb impact and relieve stress on the heel and ankle.
• Stretching exercises. Stretches for the Achilles tendon (heel cord) can reduce stress on the heel.
• Non-steroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.

In cases where the pain is bad enough to interfere with walking, a short-leg cast or "walker boot" might be required to immobilize the foot while it heals. It is not unusual for Sever's disease to recur. This typically happens when a child increases sports activities. Wearing sports shoes that provide good support to the foot and heel may help prevent recurrence. Sever's disease will not return once a child is fully grown and the growth plate in the heel has hardened into bone.

The illustration on the left shows normal skeletal anatomy of the adult foot. On the right, an x-ray of an adolescent foot showsheel padthe open growth plate of the calcaneus. It is not possible for a doctor to diagnose Sever's disease only by reviewing an x-ray, as the x-ray appearance looks similar for those with apophysitis and those without any symptoms. Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

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