Lower extremity and leg pain from sports participation manifests as a range of symptoms, from anterior leg pain to foot and arch pain, to heel and Achilles pain. In diagnosing and treating young athletes who present with this pain, we need to consider their skeletal “immaturity”, and that they have open growth plates around areas of frequent stress. One such area of stress and injury at the heel is known as Sever’s disease, or calcaneal apophysitis.

Apophyseal Injury

An apophyseal injury occurs where the tendon inserts into a bone. Repetitive stress can lead the tendon to pull at the apophysis, creating irritation around the apophysis and associated epiphyseal plate, or growth plate.

In Sever’s disease, repetitive loading through the heel from increased weight-bearing activities leads to increased pulling on the Achilles tendon at the calcaneal apophysis. Patients will complain of pain at their heel, around their calcaneus and sometimes along their Achilles tendon. This pain often increases with weight bearing during increased athletic participation. Some patients even experience pain while walking or standing. Common treatment includes rest, ice, and immobilization. Current evidence, however, offers some other treatment methods to help decrease symptoms and get patients back to play.

Immobilization

Immobilization of Sever’s disease is often recommended and even considered a “gold standard.”1 However, there is no consensus about the method of immobilization. Some recommend a full short-leg cast for two to four weeks, while others recommend a boot. The boot allows application of rehabilitative treatments.

As to prospective studies, no randomized clinical trials looked at the efficacy of the use of splints, casting, or crutches.2,4 If a fracture is suspected or imaging shows significant physeal widening, then immobilization may be adequate for initial treatment.

Severity and frequency of symptoms should also be considered with these patients. Even if you don’t choose immobilization, it is generally agreed upon that it’s best to cease the symptomatic activity, such as running and jumping, until symptoms improve.1,2,3,4,5

Stretching

There is not an agreed upon time for the use of stretching with these patients. After all, this injury is typically related to excessive pulling and stretching of the Achilles on the heel. Patients may have pain with increased dorsiflexion range of motion, which would be placing a stretch on this area.

Pre-existing gastrocnemius muscle shortening is highly correlated with Sever’s disease.1 Most research agrees on applying stretching in these populations,5,6 especially when range of motion is limited.2 A stretch can be first done in non-weight bearing with a belt or towel assisted dorsiflexion stretch through the patient’s pain-free range. As the pain improves, patients can gradually move to weight bearing stretches.

Strengthening

The decision to begin strengthening is a major shift in a patient’s treatment. Immobilization and decreased activity participation will result in weakness of their lower extremity.

Non-weight bearing exercises should be started as pain subsides. These exercises help activate the muscles around the foot and ankle. While research shows that eccentric strengthening with various heel raises are effective in adults with Achilles and heel pain,3 you should use caution when transitioning patients to weight bearing exercises. These exercises often promote increased dorsiflexion stretching and platarflexion contraction, further straining the Achilles, and possibly increasing pain.

A great recommendation is to begin heel raises with the heel on an elevated surface, such as on a short step or book. Then patients should gradually move to a lift from a flat surface.2 Static heel raises with the heels off of a step and more dynamic strengthening should only be assigned once the patient is able to complete the exercises pain-free at each stage.

Orthotics, Heel Lifts, and Taping

A common treatment for Sever’s disease is to use a heel cup or foot orthotic. Orthotics or gel heel lifts place the foot and ankle in more plantar flexion, decreasing the pull of the Achilles on the calcaneal apophysis. Several studies have recommended this treatment1,2,5,6, but most studies combine a heel cup with other treatments.4

Taping is another method of treatment. It effectively decreases strain on the Achilles tendon, reducing pain at acute stages and when transitioning back to activity.3,4

Differential Diagnosis

With any injury, perform a thorough examination of all bony structures, soft tissues, muscular strength, and observe for any possible neurological impairment. What may seem like a straightforward diagnosis of Sever’s disease may also be plantar fasciitis, stress fractures, Achilles tendinopathy, or retrocalcaneal bursitis.6 Any of these may affect your treatment method and outcomes.

When you begin treating young athletes, work to decrease their pain and maintain ankle mobility. If pain is relieved with an orthotic, heel cup, or taping, use these methods. Continue, however, to monitor the patient’s symptoms with walking and ADL’s. Symptomatic physical activity should also be limited.

Strengthening exercises should be gradually increased, from open-chain strengthening to closed-chain movements as symptoms allow. As patients progress back to their sport or activity of choice, discuss self-limiting their participation if symptoms return at any time. The symptoms of Sever’s disease may occur sporadically until skeletal maturity. Helping these patients with a variety of treatment methods will help limit their symptoms and keep them on the field.