Severs Calcaneal Apophysitis
As is has been defined, calcaneal apophysitis is an inflammation of the
apophyseal growth plate at the posterior aspect of the calcaneus. The
condition affects children between the ages of 8 and 15 years, with the highest
incidence occurring in the 10-to-12-year-olds. This condition is never seen in
the very young child or in the older child in whom the growth center has
closed. The frequency of occurrence usually is related to sports activities or
some form of strenuous exercise or activity.
Many years ago, clinicians felt that the condition was dominant in males
because of the high incidence in boys and rare occurrence in girls. Some
theorized that the hormonal changes in the male affected the apophysis by
weakening is and thus causing a greater susceptibility to injury. This maledominant theory can now be discounted because the frequency has been
found to be equal in both females and males. His is the result of increased
participation in sports-related activities by both sexes.
Another theory that has been proposed to explain this condition is an
osteochondrosis of the calcaneal apophysis. An osteochondrosis is defined as
an avascular necrosis of unknown etiology. The appearance will be a
fragmentation and/or increased density with diminution in the normal size of
the bone. The avascularity is the reason for the more dense appearance taken
on by the bone due to the loss of bone activity and metabolism.
This process has been named Server’s disease. In the early 1900’s, Dr.
Server described an increase in the density of the calcaneal apophysis with
some fragmentation in children presenting with pain in the heel after
ambulation or upon direct pressure to the calcaneal apophysis. Current
research and studies have shown that the avascularity does not occur – as
would be found in a true osteochondrosis. Additionally, the fragmentation and
altered bone density may or may not accompany the clinical signs and
complaints of painful heel syndrome in a youngster.
Traction injuries to the calcaneal apophysis also have been thought to
be a cause of the painful heel syndrome in this age group of children. His
theory assumes that there is a combined force of the plantar fascia and
Achilles tendon on the apophysis, causing it to be injured and fragmented.
Children with a short gastrocnemius/soleus complex due to either a
congenital shortening or a rapid growth spurt could produce an excessive
traction force on the apophysis. This must be looked for in all children
presenting with painful heel syndrome.
Clinical Findings
The child, either male or female, usually points out that he or she has
participated in some form of strenuous activity prior to the onset of the
symptoms. This may include running, playing basketball, gym class activities,
or increased walking, for example.
Children ages 8-15 years account for the highest incidence of this
condition. The pain usually increases with activity and is relieved with rest.
Normally there is no pain in the morning upon arising or after stepping on the
heel after a long period of rest. This is in contrast to the typical findings of an
Achilles tendonitis or plantar fasciitis, which is painful upon arising after rest
and initially will improve with exercise. The calcaneal apophyseal pain comes
on insidiously and gradually worsens with increased activity. The child
usually will report that the pain will become so intense in the heel during an
activity that will cause a noticeable limp or the need for cessation of activity.
Clinical examination usually will reveal pain on side-to-side pressure at
the posterior of the calcaneus but not at the plantar insertion of the plantar
fascia. Lower posterior plantar pressure on the heel also will elicit pain,
although this usually does not occur at the upper two-thirds of the posterior
calcaneus. Depending on the degree of injury, the child may have antalgic gait;
however, in most cases a normal gait is found. There will be notable evidence
of edema, rubor or erythema around the heel.
Radiographically, a separation at the posterior plantar apophyseal plate
will be evident in 95-98% of these cases. Sometimes there is truly a fracture of
the plantar apophysis.
Treatment:
Standard treatment is that of rest, decrease activity , heel lift and or
orthotic, non-steroidal anti inflamatories, for several weeks to
several months. In severe cases children will require a hard cast
and or wheel chair . There are some cases that will linger on till the
apophysis is fused.