When I was 11, I developed a sore heel. I was dancing at a high level, accumulating close to 18 hours of physical activity each week. My heel hurt when I plié and fondu, when I rose on to demi pointe, when I jumped and when I landed. It started in one heel only, but before too long both heels were equally troublesome. My symptoms progressed to the point where I was uncomfortable just walking around. My mum took me to a sports physician, who diagnosed me with Sever’s disease and referred me to a physiotherapist for management. It was this early encounter with health professionals that sparked my interest in the body, how it works, how it breaks, and the ways in which we can manage and prevent injury. I now see many young clients with similar conditions; needless to say I have a keen interest in helping kids (and guiding their parents) through this stage of development.
What is Sever’s Disease
Do not panic – Sever’s Disease is not a ‘disease’! It cannot be contracted or passed from one person to another. It is a ‘condition’ of adolescence, which affects the Achilles tendon attachment to the heel. The attachment site is directly over the growth plate, the apophysis, of the heel, the calcaneus. In a young person at risk, the area can be come irritated and inflamed, resulting in inflammation of the heel’s growth plate. Technically called calcaneal apophysitis, this is Sever’s disease.
The growing area of the bone is the weakest part of the osseo-musculo-tendinous unit, until it fuses in late childhood or early adulthood. It can be injured by direct trauma to the site, or through traction and mechanical stress via the tendon attachment to the bone.
What are the signs and symptoms?
Signs and symptoms that someone might have Sever’s include:
- pain on that back of the heel
- swelling around the back of the heel
- soreness during activity and ache afterwards
- may be sore or ok upon waking in the morning
- a painful gait causing a limp or toe walking on the affected side
- reduced strength and power in jumping activities
- the development of a bony lump on the back of the heel bone
How do we diagnose Sever’s?
A sports doctor or physiotherapist will generally be able to diagnose Sever’s from the patient’s history and explanation of symptoms in conjunction with their physical examination. XRay’s are typically not required, but may be necessary to rule out something more sinister. Radiological findings, such as a fragmented growth plate, are often visible in healthy, normal heels, as illustrated below.
Who does it affect?
Apophysitis can occur at any growth plate site, but calcaneal apophysitis is the most common. Sever’s affects active, young people; girls aged 8 to 13 and boys aged 10 to 15.
What can contribute to developing Sever’s?
- Activities involving running, jumping, and repeated rising movements require repeated and forceful contraction of the calf muscle which connects to the Achilles tendon, in turn placing repeated stress on the tendon’s attachment to the calcaneus
- Sports like soccer, football, basketball, gymnastics and dancing
- During periods of high velocity growth, there may be a discrepancy between the length/size of the bone and strength/length of the surrounding muscles and tendons, placing increased tensile strain on the soft tissues and their bony attachments. In line with growth is expected and normal weight gain, which will add additional load.
- Tightness and/or weakness in the calves, or stiffness in the ankle and foot, decreases the dorsiflexion (plié) range of movement and reduces shock absorption ability when landing from jumps
- Poor intrinsic foot muscle coordination and strength further reduces the ability to absorb shock when landing from aerial movements, forcing the tendon and it’s attachment to take on more load
- A sudden increase in training load can strain the tissues beyond their capacity
- Addition of new skills to a training regime can overload the tissues
- Time of the year – in Australia, kids tend to grow most in September and January, so growth-related and overuse injuries during these periods are more common
How can physiotherapy help to manage the symptoms?
I wrote a blog recently detailing strategies to help with managing acute injuries, which outlines the POLICE acronym – protect, optimal loading, ice compress, elevate. All of these methods are applicable to the management Sever’s symptoms.
Physiotherapists can be pretty clever people! We are body detectives, engineers and mechanics, and have a huge bag of tricks up our sleeve to help guide you or your child through Sever’s. In addition to those outlined in previous articles:
- Taping techniques to offload the inflamed area and promote activation of the intrinsic foot muscles
- Massage to release tight calves and feet
- Mobilising to improve ankle and foot range of motion
- Assessing biomechanics and addressing contributing factors
- Retraining optimal movement patterns
- Strengthening calves and feet
- Loading the Achilles tendon appropriately so as to maintain strength without overloading it
A physiotherapist will be able to advise the client on ways to modify their activities and adjust their loading, such as cross training, to allow activity to continue during periods of pain and incapacity. At times when symptoms are severe, the client may require rest from all activities to allow inflammation and pain to settle. Whereas when symptoms are mild or stable, the client may be able to participate in full training. For example, in a ballet class, a dancer may be able to take barre and adage in the centre, but no allegro or pointe work. Finding balance and working with what the body can tolerate on any given day is key to successful continuation of class or training.
Most kids will amass more than 10,000 steps within a normal day, so taking even 1% of stress off each and every step will help reduce stress on the tendon and growth plate.
- Wear comfortable, supportive, cushioned shoes as often as possible – eg: wearing runners instead of leather school shoes
- Wear gel heel cups in stiff school shoes and casual shoes, and use fitted heel pads in dance shoes or for activities practised in bare feet (be careful of slipping!), to assist with shock absorption during gait and protect the heel from rubbing or friction caused by stiff school shoes
- Use heel lifts in shoes to take tensile strain off the Achilles – should be adopted for acute and severe pain only as ongoing use of a heel lift can lead to a shortened, tight calf
Emotional and Motivational Recovery
See my previous blog about recovery for additional tips to address the non-physical aspects of rehabilitation.
What is the prognosis?
For the majority of sufferers, the prognosis is excellent. Symptoms will come and go, often for up to a couple of years, and will naturally resolve once growing slows.
Need some personalised advice on Sever’s? Get in touch!