Sever's Disease: No Difference Noted in Various Treatments

If your son or daughter gets heel pain, nagging or very acute, between ages of 8 and 14, they may have an irritation of their growth plate. This is called Sever's disease or calcaneal apophysitis. The article documents that you can use physical therapy, orthotics, or a just wait and see attitude, and they probably will get better. But why not do it all? Find an insert that transfers the weight to the arch, home physical therapy with ice baths 20 minutes twice a day, formal physical therapy with electro-galvanic stimulation to ease the bone swelling, and some activity modification to not continue injuring it. Non-painful stretching of the achilles is also great 3-4 times a day. 

http://journals.lww.com/pedorthopaedics/Citation/2016/03000/Treatment_of_Calcaneal_Apophysitis___Wait_and_See.8.aspx

Ollier's Disease and Calcaneal Apophysitis: Email Advice

From Wikipedia:

Ollier disease is a rare nonhereditary sporadic disorder where intraosseous benign cartilaginous tumors (enchondroma) develop close to growth plate cartilage. Prevalence is estimated at around 1 in 100,000. Normally, the disease consists of multiple enchondromas which usually develop in childhood. The growth of these enchondromas usually stops after skeletal maturation. The affected extremity is shortened (asymmetric dwarfism) and sometimes bowed due to epiphyseal fusion anomalies. Persons with Ollier disease are prone to breaking bones and normally have swollen, aching limbs.

Hi Dr. Blake,

I am truly at a loss for my son’s pain in his rt. Foot.  The pain is in his heel and it just isn’t getting any better.  A little history… my son has Ollier’s Disease and has had two surgeries on his Rt. Leg.  1^st surgery was May 2011 femur fracture, rod placement.  2^nd surgery was leg lengthening and corrective alignment of knee.  The leg lengthening wasn’t exactly a success as he was growing bone too quickly which forced us to double up on the amount of turns each day to avoid the bone from growing together.  This caused him to have severe nerve pain, that lasted about a year.  He was taking Neurontin to control this pain.  He also ended up with stress fractures once he could walk but it was the nerve pain in his foot that was the worst.  He ended up still being short in that leg and continues to be about an inch short.  During this time, his rt. Foot was 2 ½ sizes smaller than his left foot.  Today he is only about one size different. Rt. Shoe is a 3 left shoe is a 4.  He also has an internal lift in his rt shoe.  He still has trouble going down stairs, he takes them one at a time vs. a continue flow.  He recently had to have surgery on his left arm they actually did a salvage surgery to save his left forearm from amputation creating a one bone forearm in Sept. 2014. He again had nerve pain and was put on Neurontin which he is still taking.  

On March 15^th he was playing with friends being very active (which he really hasn’t been able to do) for about 4 hours.  He ended up coming in basically crawling because he couldn’t walk and started complaining that his heel really hurt with some pain on the top of his foot but mostly just his heel. There was no swelling, no redness, but it hurt to touch it and move it.  They were doing a lot of jumping as they were trying to make a big look out nest on top of a very large snow pile.  We took him to our local urgent care, they took x-rays and said they looked ok that it was most likely a deep, deep bruise and to stay off of it and rest it. 

  Three days went by and he wasn’t getting a lot of relief from the ibuprofen he was taking around the clock, icing it helped somewhat, but he was still pretty miserable.  I ended up taking him to Children’s in Boston where he is followed by two ortho doctors. He saw a Dr. on call, they took more xrays, and placed him in a boot.  He couldn’t stand the boot, he said it made the pain worse, he tried to wear it for short periods of time but it just wasn’t working.  The pain was still the same and not getting any better.  We went back to Children’s and this time they put him in a cast.  The cast was better but it still didn’t provide enough relief.  He was asking for pain medicine around the clock so I started thinking that it might be more nerve related.  We went back to Children’s yesterday and they took off the cast.  When they took the cast off he was in a ton of pain and said it felt better in the cast.  UGH!!!!   So, they ended up making a bi-valve cast so he can remove it and I can massage his foot.  He is absolutely miserable still, he keeps saying he just doesn’t know what to do and frankly neither do I.  We are going to be seen by the pain clinic at Children’s tomorrow and I’m hoping that you can give me your thoughts based on the xrays and my description.  Sometimes another set of eyes can bring something else to light.  This pain wakes him up at night, he has trouble falling asleep, he just wants to be a normal boy!!! 

PLEASE, PLEASE, PLEASE share your insight with me.  I would be beyond grateful for any advice and can be reached by phone or email.

Thank you & Warmest Regards,

Dr Blake's comment: Thank you so very much for the email. The heel looks normal on xray, but the pain from calcaneal apophysitis (yes, a normal injury) can be intense. The treatment is ice soaking 20 minutes (heel in the ice bucket only, not the entire foot) 3-4 times a day since the pain is primarily inflammatory. These growth plates stay open in boys until 14, so he could have a few episodes. You ice 3 days longer than you need to with each episode. After 5 days of icing, let me know what is happening. You should be aware of Calmare Pain Therapy for nerve pain. Go on their website, I am not sure if there are age restrictions, but it can be used on any part of the body, and it non-invasive. Hope this helps some. Rich

Calcaneal Apophysitis: Sever's Disease Email Correspondance

Dear Dr Blake:
My son has suffered with this for about 1 year. He is nearly 11. Exactly as you described in one of your previous posts on calcaneal apophysitis. He had x-rays today, compared them to the blog post image. It is identical.

The growth plate in the back of the heel in children between 8 and 14 can get inflamed due to the pull of the achilles tendon which attaches into it. This pain syndrome is called Sever's Disease or Calcaneal Apophysitis.

 Have you ever used medrol dose pack to relieve severe inflammation? He started that yesterday. A month of rest (no activity other than school), advil 400 mg 3X a day did not help alleviate pain. I am praying for some relief for him.

Dr Blake's response:

Hey Dad, sorry to hear about your son. This is a nasty problem at times, since your son is still 10 and the growth plate will be opened until 14 or so.  Definitely medrol dose pack is used at that age alot. Commmonly for asthma and poison oak, but severe inflammation of any cause it can sure do the trick. It should only be used once per year, since it is cortisone, but sounds like he really needed it.  Give me a progress report after he goes through the medication. 

Once he is off the cortisone, he should go back to the Advil (same dosage), ice for 20 minutes twice daily, and do contrast baths once daily. This attack on the inflammation should knock it out. The order of ending is 1) medrol dose pack, 2)advil, 3) contrasts, and then 4)icing. The medrol dose pack is a one time thing to knock down the inflammation, whereas the other 3 should be done until your son is back to full activity. I will try to be even clearer on my post today. 

He really needs to make the heel area of his workout shoes softer with one of a variety of inserts found online or in a local sporting good store or pharmacy. He needs to stretch his achilles tendons, both straight and bent knee, 5-7 times daily to minimize the tension on the heel bone. Some patients need custom orthotics to off weight the heel and get the weight into the arch. Other patients need physical therapy, especially EGS with contrasts to flush the inflammation. Find out if the heel pain feels better in shoes vs barefoot. Golden Rule of Foot: Any time barefoot feels bad with an injury, avoid for 3-6 months. 



Overall, you are doing what is right. You have to create that pain free environment by reducing the inflammation. Once the inflammation is down enough with all the modalities listed above, and to where the pain level is between 0-2, you can safely gradually increase activity as long as the symptoms stay the same. Other than the limited medrol pack, I recommend gradually weaning off things. Golden Rule of Foot: Stay on safe treatments 2 weeks longer than you think you need to. 

Sever's Disease: Growth Plate Injury in a Child's Heel

     The above photo is of the heel bone in a 12 year old boy. The heel bone is called the "calcaneus" and has an important growth plate at the base. Boys from 8 to 14 and Girls 7 to 13 can have pain develop in this area either from the pull of the achilles tendon, or the pull of the plantar fascia. After those ages, the growth plates fuse and there can no longer be a source of pain. With my 2 boys growing up, and playing tons of sports, both had this problem. Ice soaking (see separate post) for 20 minutes twice daily really minimizes the soreness, but you must start as soon as the soreness begins. At least they could just dip their heel into the ice water, not the entire foot. We always joked as they iced that they were now guaranteed to grow more.

     The basic rule is to create a pain free environment with no limping. Hopefully, they can continue playing, but the parents and coaches must watch for limping/favoring.  Electrical Stimulation with ice is a good physical therapy modality along with achilles stretching without pain. If you look closely at the photo, you can see how the achilles tendon attaches right on it, and can irritate it endlessly. Some form of heel cushion or lift, if it makes it feel better, is also helpful. 

     I will always remember Alex, short for his age at 10 years old, less than 5 foot tall,  and with one of the worse, long-lasting, stubborn cases I have treated. The symptoms remained significant for almost one year. When all was said and done, by 14 years old,  he was 6 feet 2 and still growing.