Case Study 13: Heel pain in a Child

A 13 year old presented with ongoing pain in the right heel. The pain was worse after sport and at night when being very active during the day.

There was pain when performing the ‘apophyseal squeeze test’ on the right side only

Performing an ultrasound of the heel indicated fragmentation of the posterior aspect of the calcaneum

This problem is known as severs disease.

What is Severs disease?

Severs disease is also called calcaneal apophysitis, which as the name suggests is inflammation of the calcaneal apophysis (growth plate).

This problem usually affects young adolescents who complain of pain at the back of the heel. The pain is more common after exercise and can last for hours or days after. The pain can happen in one leg or both legs

TSevers Disease typically occurs during the growth spurt of adolescence. The time at which the growth spurt occurs differs and can happen between the ages of:

8 to 13 for girls and 10 to 15 for boys.

Causes of Severs Disease

Unlike an adult heel bone the heel bone in a child is in two parts connect by a cartilage growth plate (see picture below)

Xray of a Childs Foot Xray of a Adults Foot

The heel’s growth plate is sensitive to repeated running and pounding on hard surfaces. For this reason, children and adolescents involved in soccer or basketball are especially vulnerable.

Other potential causes of calcaneal apophysitis may include a tight Achilles tendon, and biomechanical problems such as flatfoot or a high-arched foot.

Diagnosis of Severs Disease

Diagnosis is generally made with specific signs and symptoms – when the pain occurs and the location.

Most children with this problem will have a ‘positive apophyseal squeeze test’  (pain when squeezing the heel).

Ultrasound Imaging is also beneficial when diagnosing Severs disease. Ultrasound images of the apophysis are usually fragemented with increased vascularisation.

severes ultrasound(Fragmentation of the calcaneal apophysis as seen on ultrasound)

Treatment of Severs Disease

In the majority of cases severs disease is self limiting, which means it will go away regardless on what you do once the growth plate has fully formed. The main goal of treatment is to minimise the pain associated with this problem. This can include

  • Activity reduction
  • Orthotic management
  • Heel raises to reduce the tension in the Achilles
  • Gel Heels
  • Supportive footwear
  • Stretching
  • Taping
  • Night Splinting