You are in: eMedicine Specialties > Orthopedic Surgery > FOOT AND ANKLE Sever DiseaseArticle Last Updated: Jul 12, 2004AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Mark A Noffsinger, MD, Clinical Instructor, Department of Orthopedic Surgery, Michigan State College of Human Medicine; Medical Director, Deptartment of Orthopedic Surgery, Bronson Methodist Hospital, Consulting Staff, Kalamazoo Orthopedic Clinic Mark A Noffsinger is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Orthopaedic Medicine, American College of Physician Executives, American Fracture Association, American Medical Association, American Medical Directors Association, Christian Medical & Dental Society, Indiana State Medical Association, International Society on Thrombosis and Haemostasis, Michigan State Medical Society, Mid-America Orthopaedic Association, and Phi Beta Kappa Editors: James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St. Luke's Hospital, Jacksonville, Florida; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director Designate, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: Sever's disease, calcaneal apophysitis, calcaneal epiphysitis, traction apophysitis, Achilles tendon pain, heel pain INTRODUCTIONSection 2 of 11
  BackgroundSever disease is a painful inflammation of the calcaneal apophysis. It is classified with the child and adolescent nonarticular osteochondroses. (The other disease in this group is Iselin disease, which is inflammation of the base of the fifth metatarsal.) The etiology of pain in Sever disease is believed to be repetitive trauma to the weaker structure of the apophysis, induced by the pull of the tendo Achilles on its insertion. This results in a clinical picture of heel pain in a growing active child, which worsens with activity. In 1912, J.W. Sever, MD, first described this condition in the New York Medical Journal. He described it as an inflammation of the calcaneal apophysis resulting in the clinical symptoms of pain at the posterior heel, mild swelling, and difficulty with walking. PathophysiologyThe calcaneal apophysis develops as an independent center of ossification (possibly multiple). It appears in boys aged 9-10 years and fuses by age 17 years; it appears in girls at slightly younger ages. During the rapid growth surrounding puberty, the apophyseal line appears to be weakened further because of increased fragile calcified cartilage. Microfractures are believed to occur because of shear stress leading to the normal progression of fracture healing. This theory explains the clinical picture and the radiographic appearance of resorption, fragmentation, and increased sclerosis leading to eventual union. The radiographs showing fragmentation of the apophysis are not diagnostic because multiple centers of ossification may exist in the normal apophysis, as noted above. However, the degree of involvement that occurs in children displaying the clinical symptoms of Sever disease appears to be more pronounced. FrequencyInternationalAlthough no exact figures of the occurrence of Sever disease exist, it is a relatively common problem in growing active children. Mortality/MorbidityAlthough no well recognized long-term sequelae of untreated Sever disease exist, Sever disease causes pain that can limit performance and participation in sports, and, if left untreated, the pain can significantly limit even simple activities of daily life. SexIncidence is higher in boys than in girls. Micheli and Ireland reported on 85 patients, 64% who were male (Micheli, 1987). AgeSever disease occurs most frequently in active 10- to 12-year-old boys. In Micheli and Ireland's report on 85 patients, the average age of presentation was 11 years 10 months for boys and 8 years 8 months for girls (Micheli, 1987). CLINICALSection 3 of 11
HistoryThe typical clinical presentation is the active child (aged 9-10 y) who complains of pain at the posterior heel made worse by sports, especially those involving running or jumping. The onset is usually gradual. Often, the pain has been relieved somewhat with rest and, therefore, patiently monitored by the patient, parents, coaches, trainers, and family physicians, expecting it to resolve. When the pain continues to interfere with sports performance and then with daily activities, further consultation is sought. PhysicalPhysical examination varies depending on the severity and length of involvement. Bilateral involvement is present in approximately 60% of cases. Most patients experience pain with deep palpation at the Achilles insertion and pain when performing active toe raises. Forced dorsiflexion of the ankle also proves uncomfortable and is relieved with passive equinus positioning. Swelling may be present, but usually is mild. In long-standing cases, the child may have calcaneal enlargement. CausesSever disease, like other similar conditions (eg, Osgood-Schlatter disease, little-leaguer's elbow, iliac apophysitis), is believed to be caused by decreased resistance to shear stress at the bone–growth plate interface. Studies have indicated that traction apophyses have a higher composition of fibrocartilage than epiphyses subjected more to axial load, which are composed of predominately hyaline cartilage. The anatomy of the calcaneal apophysis lends to significant shear stress because of its vertical orientation and the direction of pull from the strong gastroc-soleus muscle group (see Image 3). DIFFERENTIALSSection 4 of 11
Achilles Tendon Pathology Calcaneus Fractures Non-neoplastic Conditions Simulating Bone Tumors Osteomyelitis Tarsal Coalition WORKUPSection 5 of 11
Imaging Studies
Histologic FindingsSever disease is characterized by disorder of the normal process of enchondral ossification. TREATMENTSection 6 of 11
Medical CareAs children become involved in sports at younger ages and compete at higher levels, and as expectations of the participant, parents, and coach increase, incidence of overuse syndromes increases in growing athletes. When Sever disease occurs, not only does the child experience pain that can limit performance and participation, but, if left untreated, the pain 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 for 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.
ActivityLimitation of activity (especially running and jumping) usually is necessary (see Treatment, Medical Care). MEDICATIONSection 7 of 11
Judicious use of anti-inflammatory agents may be helpful for patients wishing to avoid limiting their sports activities (see Treatment, Medical Care).
Drug Category: Nonsteroidal anti-inflammatory drugsHave analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
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REFERENCESSection 11 of 11
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