Sever's Disease and Heel Pain in Children

Heel pain is common in children. While it may be the result of a specific injury, it is also commonly caused by something called Sever's disease, a type of overuse syndrome similar to shin splints or Osgood-Schlatter disease.

Children with Sever's disease (also known as calcaneal apophysitis) develop micro-fractures where the Achilles tendon inserts on the calcaneus (the large bone that makes up the heel of the foot). These microfractures can cause pain depending on the type of activity your child is doing. The pain generally gets worse with activity and improves with rest.

Causes

Sever's disease is more common in boys and typically occurs when the child is between 8 and 13 years old. Although it can affect both heels, it more commonly just affects one. It is a disease of overuse, most often caused by playing sports or any activity which involves a lot of heel motion or impact.

Sever's disease is commonly seen at the beginning of a school sports season. Children going through adolescent are especially prone to the disease as the heel bone will typically grow faster than the leg. It more often occurs in children whose feet and ankles roll inward when standing (referred to as either "flat feet" or over-pronation).

Symptoms and Diagnosis

Heel pain is the defining symptom of Sever's disease, located either to the back (posterior) or toward the front adjacent to the arch (plantar). Unlike a heel or ankle injury, there will be little to no swelling or redness. The pain, however, can sometimes be so severe as to cause limping or a tiptoed gait.

Diagnosis involves a simple squeeze test in which patient lies prone on the examining table with their knees flexed at 90 degrees. The doctor will then squeeze the heel at the back, middle, and side of the heel to determine where the pain is.

Plantar fasciitis is another common cause of heel pain, but unlike Sever's disease, the pain is mostly felt when the activity is first started. After 10 to 15 minutes of activity, the pain will "work itself out" and resolve its own. This is the main differentiator between the two conditions.

Treatment

Treatment of Sever's disease is focused on a combination of recuperation and physical therapy techniques. Known as the RIME method, the technique involves:

• Rest (or, in the case of children, relative rest)
• Ice packs or compresses
• Massage of the injured foot
• Exercises that stretch and strengthen the Achilles tendon, hamstring, and calf muscles

Heel pads, lifts, or cups are also recommended to protect the heel and minimize the impact of walking or bumps. A firmer heel pad is better is preferable to softer, cushioned one.

For severe pain, a short leg cast for four to six weeks may be helpful. If the pain isn't too bad, a heel pad and exercise may suffice. However, if the symptoms don't improve, immobilization may be needed.