Recalcitrant Foot and Ankle Entities: Sever’s Disease

ATPC

Dec. 2016

Special thanks to Ryan Freedman

Lecture Objectives

• Case presentation of Sever’s disease

• Pathophysiology of Sever’s disease

• Current discussions in Sever’s disease

• Future considerations in Sever’s disease

Case Presentation

• HPI: 10 year old male who plays basketball and soccer presenting with bilateral heel pain. Pain began 2 months ago. Parents initially tried rest which was somewhat helpful, but pain recurs when he returned to his sports.

• Physical Exam:

• Point tenderness upon palpation of the Achilles insertion and most posterior aspect of the calcaneus. Pain with performing toe raises, pain with forced dorsiflexion. –Swelling or ecchymosis.

• Neg Calcaneal squeeze test if squeeze is directed to body of the calcaneus, tender if more posterior

• DDX: Sever’s apophysitis, Plantar Fasciitis, Painful Heel Pad Syndrome, Achilles Tendinitis, Retrocalcaneal Bursitis, Calcaneal Stress Fx

• Rare: Bone Cyst, Bone Tumor, Osteomyelitis

Case Presentation

• Workup:

• X-Ray

• “fragmentation” of the calcaneal apophysis seen on contralateral films

• Not diagnostic, but can be used to exclude fracture or tumor

• Treatment:• Rest from inciting activity

• suggest use of heel lifts in shoes and address lack of support and/or cushioning in cleats

• PT- stretching and eccentric loads?

• Cold packs

• NSAIDs

• May consider short leg cast/boot for immobilization if more severe

Apophysitis

• Painful inflammation of a bony outgrowth and especially the area of active growth at the end of bone (as of the heel or shin) where a muscle or tendon attaches.1

Epidemiology

• Most common cause of heel pain in young athletes and accounts for 8% of all pediatric overuse injuries

• M>F, most commonly 10-12 years old (8-14 yo range)

• Seen in athletes participating in sports requiring running, jumping, and plantar-flexion activation and often in cleated sports

• Basketball, soccer, track, gymnastics, dance

Pathophysiology

• Classified as an “Overuse Injury”

• Maturing apophysis is subject to significant loading and tensile stress

• Apophysis is structurally weak compared to other structures

• Thought to be due to rapid growth spurts

• Repetitive traction from the gastrocnemius-soleus complex leads to “micoavulsions”

• Self limited and resolved with closing of calcaneal physis

• In <1%, can progress to calcaneal avulsion injury

Current Discussions

• Imaging needed to diagnose Sever’s apophysitis?

• Reducing Inflammation vs. changing biomechanics

• Is immobilization necessary?

• Is there a role for surgery?

What imaging is needed?

• No imaging is needed if presentation is typical (i.e. age 10-12, bilateral, active patient)

• X-ray is not diagnostic, but can rule out other causes of heel pain (tarsal coalition, fracture, cyst)

• Study by Hosgoren et al. of 21 symptomatic heel pain showed equal sensitivity/specificity of radiographs versus ultrasound for diagnosis of Sever’s

• Ultrasound is a good method to avoid unnecessary radiation

• MRI reserved for ruling out conditions such as osteomyelitis or stress fracture

Modalities of Treatment

• Study by Wiegerinck et al. compared 101 patients divided into three treatment modalities of wait and see, heel raise inlay, and eccentric exercises

• Early improvement with heel raise inlay (P<0.01), but all three equivalent at final follow up

• James et al. in the British Journal of Sports Medicine found in a study of 133 children that at the endpoint of the study this was no clear advantage to any of their interventions

Modalities of Treatment

• Systematic review completed by James et al. found that there is no consensus on the most effective treatment between minimizing inflammation (Rest, NSAIDs) or changing biomechanics (heel lifts, orthoses, taping)

• Authors felt that there is limited high quality evidence to support current treatment approaches

Immobilization?

• Can be used effectively in refractory cases, but only after more testing to rule out other more serious causes of heel pain

Surgery?

• There are no studies to suggest that surgery plays any role in the management of Sever’s disease

Information For Patients

• http://www.amssm.org/FactsheetPDFS/SeversDisease-115.pdf

• Nice summary of key points for patients to know about Sever’s disease and its treatment.

Summary Points

• Sever’s disease affects adolescents and is characterized as an overuse injury

• It is usually self-limiting, but symptoms can be improved with a combination of rest, ice, NSAIDs, orthoses or heel lifts

• Chronic (or possibly the more severe presentations) “Sever’s disease” may require further evaluation to rule out more serious causes of heel pain

• Future studies should continue to focus on efficacy of specific treatment protocols and limiting unnecessary diagnostic testing

Citations• 1. Anderson, J. G., Bohay, D. R., Eller, E. B., & Witt, B. L. (2014). Gastrocnemius recession. Foot and Ankle Clinics, 19(4), 767-786.

• 2. Chang, G. H., Paz, D. A., Dwek, J. R., & Chung, C. B. (2013). Lower extremity overuse injuries in pediatric athletes: Clinical presentation, imaging findings, and treatment. Clinical Imaging, 37(5), 836-846.

• 3. Hoang, Q. B., & Mortazavi, M. (2012). Pediatric overuse injuries in sports. Advances in Pediatrics, 59(1), 359-383.

• 4. Hosgoren, B., Koktener, A., & Dilmen, G. (2005). Ultrasonography of the calcaneus in sever's disease. Indian Pediatrics, 42(8), 801-803.

• 5. James, A. M., Williams, C. M., & Haines, T. P. (2013). "Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (sever's disease): A systematic review". Journal of Foot and Ankle Research, 6(1), 16-1146-6-16.

• 6. James, A. M., Williams, C. M., & Haines, T. P. (2016). Effectiveness of footwear and foot orthoses for calcaneal apophysitis: A 12-month factorial randomised trial. British Journal of Sports Medicine,

• 7. Launay, F. (2015). Sports-related overuse injuries in children. Orthopaedics & Traumatology, Surgery & Research : OTSR, 101(1 Suppl), S139-47.

• 8. Orava, S., & Virtanen, K. (1982). Osteochondroses in athletes. British Journal of Sports Medicine, 16(3), 161-168.

• 9. Sando, J. P., & McCambridge, T. M. (2013). Nontraumatic Sports Injuries to the Lower Extremity. Clinical Pediatric Emergency Medicine, 14(4), 327-339.

• 10. Shields, N. (2016). Wait and see, heel raise and eccentric exercise may be equally effective treatments for children with calcaneal apophysitis. Journal of Physiotherapy, 62(2), 112; discussion 112.

• 11. Tu, P., & Bytomski, J. R. (2011). Diagnosis of heel pain. American Family Physician, 84(8), 909-916.

• 12. Wiegerinck, J. I., Zwiers, R., Sierevelt, I. N., van Weert, H. C., van Dijk, C. N., & Struijs, P. A. (2016). Treatment of calcaneal apophysitis: Wait and see versus orthotic device versus physical therapy: A pragmatic therapeutic randomized clinical trial. Journal of Pediatric Orthopedics, 36(2), 152-157.

• 13. http://www.merriam-webster.com/medical/apophysitis