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

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.