Boyd W. Haynes III, MD
I recently had an employee tell me that her friend’s grandson had been complaining of horrible heel pain. She said that he was around 12 years old, played football and that his pain was so bad it caused him to cry and walk around on his tiptoes. Of course, everyone had an opinion about what was causing the problem. One of the boy’s relatives said that he must have bone spurs to cause that much pain. My employee suggested plantar fasciitis. Another friend suggested an Achilles tendon strain. All might be good guesses, but none of them nailed the diagnosis, which is Sever’s Disease, named after the Orthopaedic physician who first described the condition. In this article, I will describe the condition and symptoms, its causes and treatments. Sever’s Disease can be painful, but it is temporary and does not, usually, cause any long-term problems.
Sever’s Disease is not a “disease”, but is a fairly common condition that afflicts active adolescents who are near or going through puberty. It can also impact overweight or obese adolescents, those who stand for long periods, those who have foot problems and those who have one leg shorter than the other. During adolescence, the body undergoes growth spurts which can impact the knees, heels or other areas where there are growth plates. There is a growth plate in the heel, called an epiphyseal plate, which sits at the end of a growing bone, where cartilage cells grow and eventually turn into bone. The problem starts when the Achilles tendon (attached near the heel) becomes irritated and inflamed. When the bone grows faster than the attached Achilles tendon (during a growth spurt), the tendon can become over-stretched and inflamed. That is the process that happens in Sever’s Disease.
When I see an adolescent patient for heel pain, Sever’s Disease is what I first suspect, based on their description of the problem. I often see kids when they start playing a sport for the first time or at the start of the season. Most often, the sport will involve a great deal of heel movement or pressure being placed on the heel. The patient may also complain of tenderness, swelling or redness of the heel. They may exhibit a limp or walk on their tiptoes to avoid putting pressure on their heels.
I do not perform x-rays to confirm my diagnosis as an x-ray does not show inflammation of the soft tissues. I do order x-rays to ensure that there is nothing structurally wrong with the bones of the foot, such as a fracture. I ask questions about when the pain started, when it is worse through-out the day, and I also can perform a simple tests which can confirm that we are dealing with Sever’s disease.
Treatment for Sever’s Disease is often palliative, as the condition will resolve with rest, activity modification and/or when the growth plate hardens and becomes bone. Most often, rest is all that is needed. However, highly-motivated young athletes may find it very difficult to take a break from the activities they enjoy or when they are part of a team. It helps to reinforce with the patient that the rest period will be temporary and that they will quickly feel better as the inflammation subsides. However, if the patient adamantly refuses to sit out of practice or games, we may try compression wraps and ice to reduce inflammation quickly. However, rest is the best medicine for this condition and full-resolution of the condition may not be achieved quickly without it.
I may recommend taking an over-the-counter anti-inflammatory medicine for pain, icing the heel in the morning and applying heat in the evening, elevation of the heel, and stretching exercises. Sometimes, it helps to have the patient wear shoes that do not rub on the back of the heel, like clogs. Heavy or cleated athletic shoes should be avoided while recovering. Rarely, I may have a patient with a particularly stubborn case of inflammation. For those patients, I may prescribe a prescription anti-inflammatory, orthotics, physical therapy or casting of the foot. Luckily, most cases resolve within a matter of weeks or a few months. The problem can recur if activity resumes too quickly or if the adolescent continues to grow a while longer. Some unusual cases are stubborn and can linger until full maturity to resolve (sometimes up to two years).
This condition can be deterred by ensuring that adolescents wear well-fitting shoes that are supportive AND shock-absorbing. It is also important that a stretching regimen be followed to help the Achilles tendon and ligaments stretch to meet the demands of growing adolescent bodies. Exercise that involves lots of running on hard surfaces should also be avoided. It is also important that adolescents who are overweight or obese be encouraged to lose weight to reduce the amount of pressure on their heels.
Finally, to help the parents deal with a child that wants to continue sports, despite the pain, I give them my golden rule of adolescent sports…“The child may play and not complain OR not play and complain”!