Distal calcaneal apophyseal fracture in young
athletes: two cases report
Miguel Pereira Filho, MD
Mauro Dinato, MD
Marcio Freitas, MD
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I have no potential conflicts with
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Introduction
• Sever apophysitis is a
major cause of foot pain
in children.
• Typically affects young
athletes who perform
activities related to
running and jumping,
such as football and
gymnastics.
Introduction
• Benign course, in general
• Treatment: stretching, rest
and modification of physical
activities
• Resolution of the symptoms in
a period of two weeks to two
months
Introduction
• Nowadays, the young
athletes practices
vigorous physical
exercises leading to
appearance of
complications
• We will report 2 cases of gymnasts with Sever
disease that developed avulsion of the distal
epiphysis through the plantar fascia
Case 1
• Female, 15 years old, heel pain for months
• Worsening of symptoms after intensifying
exercises
• She was diagnosed with Sever, used
immobilizing brace for 6 weeks, 4 of them non
weight bearing
• Gradually returned to training without
symptoms.
Case 1
• 11 months later, when starting to
jump she felt pain at the site of
her previous injury.
• Avulsion of the distal portion of
the epiphysis was diagnosed.
• She was treated surgically, with
resection of the fragment.
• 4 weeks later, returned to full activities.
• 6 weeks after surgery, she was competing on the
uneven bars.
Case 2
• 15 years old boy, which presented severe
pain in the plantar region of the right foot
after jump.
• Three months earlier, he was already
presenting pain, which had been
worsening after workouts.
• No treatment or change in their physical
activity was instituted until the worsening
of symptoms
• The X ray showed avulsion of the distal portion of the calcaneal
apophysis with plantar and medial deviation.
• The treatment consisted on resection of the fragment.
• He returned to training in 12 weeks.
Discussion
• Sever's disease was first described in
1912 and used to affect overweight and
physically active children and adolescents
• With the increasing frequency and
intensity of exercises, the apophysitis is
now also reaching athletes and nonobese children.
Imai Y, et al Calcaneal
• Sports that involve running and jumping apophyseal avulsion fracture.
have increased incidence of the disease, Arch Orthop Trauma Surg.
2007 Jul;127(5):331-3.
soccer in particular
• Recently, some authors described avulsion injuries of the
epiphysis in patients with Sever.
• Almost all injuries described occurred in the proximal
portion of the epiphysis (avulsion through the Achilles
tendon).
Discussion
• Studies using magnetic resonance imaging
showed the presence of bone edema and
hemorrhage in the metaphyseal bone, near
the epiphysis in children suffering from Sever.
• After treatment, these changes disappeared.
• The author concludes that a stress fracture
occurs near the epiphysis, and the treatment
should be more careful, including non-weight
bearing immobilization.
Discussion
• The 2 cases described here, as well as others
in the literature, demonstrate that patients
with Sever can develop more serious injuries.
• This risk group is formed by individuals who
do intense physical activities, in particular in 2
sports: soccer and gymnastics.
• We suggest that, in patients who are at higher
risk of complications, a more careful
treatment must be instituted, avoiding early
return to sports
References
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