CALCANEAL APOPHYSITIS
Synonyms and Keywords
Heel pain, Sever’s disease.
What is a Calcaneal Apophysitis?
Calcaneal apophysitis is a painful inflammation of the growth plate (apophysis) at the back of the heel bone (calcaneus), where the Achilles tendon inserts. It normally affects children between 7 and 15 years of age, because the calcaneus is not fully developed until a child is at least 14 years old. Since the apophysis from which new bones grow is made up of cartilage and is softer than mature bone, the child is more susceptible to injury to that part of the body. Therefore, when impact or disturbance is exerted repeatedly on the growth plate and heel bone through running, jumping, climbing, etc., the stress can easily produce trauma that leads to pain. This is especially true for young boys and girls who are physically active and participate in sports.
Calcaneal apophysitis also called Sever’s disease — named for JW Sever who characterized it in 1912 — though it is not a true “disease” at all. It is, however, the most common cause of heel pain in children and can occur in one or both feet. It differs from the adult variety in that while heel pain in adults usually subsides after some walking, calcaneal apophysitis generally doesn’t get better in this manner but just the opposite: walking typically makes the pain worse!
Sever’s disease is one of several different orthopedic diseases of the joint that occur in children (or “osteochondroses”), and is related to the Osgood-Schlatter disease that affects the knee rather than heel.
What Causes a Calcaneal Apophysitis?
Overuse and stress on the heel bone through participation in sports is a primary cause of the calcaneal apophysitis. The repetitive pressure and exertion while playing soccer or basketball, or simply excessive running like a kid typically does will put strain on the apophysis, possibly causing minor trauma or tear of the cartilage. It can be almost epidemic at the start of certain sports seasons, especially if the game is played on a hard surface during winter.
Heavier or obese children are believed to be at greater risk for developing calcaneal apophysitis due to the greater weight bearing down on the heels and growth plates that causes excessive traction on the still-growing bones and tendons. Biomechanical problems such as a high-arched foot or flatfoot can also be a contributing factor.
Another potential cause is a tight Achilles tendon or tight calf muscles. Because running and jumping generate a large amount of pressure on the heels, both are risk factors for they increase the tension of the growth center. Wearing shoes with poor heel padding or poor arch support can make the situation worse or even originate the condition in the first place.
For unknown reasons, some children can be more prone than others to calcaneal apophysitis. It does occur more frequently in children who pronate, and in more than half of the cases (approximately 60%) the condition affects both heels.
Who Gets a Calcaneal Apophysitis?
The condition is seen only in boys and girls from 7 to 15 years old and does not affect adults, since the two bony regions around the heel and apophysis fuse together around age 16 to complete the growth process.
Among the age range, calcaneal apophysitis is most prevalent in physically active boys and girls between 10 and 12 years old. Given a developing heel growth plate is sensitive to the repetitive pounding from running and jumping on hard surfaces, it is not surprisingly, then, that children and adolescents involved in track, gymnastics, soccer, or basketball are particularly vulnerable to calcaneal apophysitis.
What are the Symptoms of a Calcaneal Apophysitis?
Pain is usually felt at the back and side of the heel bone, and sometimes in the back or bottom of the heel. Squeezing the sides of the heel bone is often painful. In more severe cases, the child may be limping or walking on toes to avoid putting pressure on the affected heel(s). The child is usually relieved of the pain when not active, only to have it return when re-engaging in a sport activity, and have difficulty running, jumping, or climbing — all of which worsen the symptoms!
Heel pain in children can often return after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of calcaneal apophysitis.
How do You Diagnose a Calcaneal Apophysitis?
Doctors will diagnose a calcaneal apophysitis based on physical examination of the lower leg, ankle and foot, along with a review of the child’s medical history, recent activities, and symptoms. To rule out other more serious conditions, a doctor may order x-rays that are a normal procedure for diagnosing Sever’s disease.
How do You Treat a Calcaneal Apophysitis?
Calcaneal apophysitis has no known long-term complications and is self-limiting; that is, it will go away when the two parts of bony growth eventually join together in a natural process (occurring around 16 years of age). Until then, however, it can be very painful and can restrict a child’s activities while waiting for it to subside, so treatment to relieve pain is often advised.
Management of the condition by a health professional is commonly recommended. There are a few very rare problems that may be causing the pain, so a correct diagnosis is important.
Self-Care at Home
The following is suggested for a child with calcaneal apophysitis:
- Cut back on sporting activities. It’s not necessary to stop completely, just reduce the time and intensity until symptoms improve. Athletic strap or tape is sometimes used during activity to limit the ankle-joint range of motion. If the condition has been present for a while, a longer or even total break may be in order later.
- Use a soft, cushioning heel raise to reduce the pull from the calf muscles on the growth plate, while increasing the absorption of shock to the heels.
- Stretch the hamstring and calf muscles with simple exercises that do not cause pain in the apophysis, 2-3 times a day.
- Placing an ice pack on the heel(s) after activity for 20 minutes can be very conducive to recovery as it reduces pain and inflammation. This should be repeated 2-3 times daily, and as often as every hour when experiencing soreness.
- Always have comfortable footwear on to minimize impact with the surface.
- Anti-inflammatory medication may be needed to alleviate intense pain or relieve symptoms not responding to the measures above.
The goal is to return your child to the sport or activity as soon and safely as possible. If the child returns to activities too soon or plays with pain, the injury can worsen, thus leading to chronic pain and difficulty with sports. Because everyone recovers from injury at a different rate, how soon the condition resolves will determine the time of the child’s return to activity, not how long it has been since the condition first arose. Generally, the longer a child has had symptoms before starting treatment, the longer it will take for the injury to heal. If the pain recurs upon resuming activity, the child should rest, ice, and stretch until the pain is gone before trying to return again.
Topical Professional Treatments
A doctor may choose one or more of the following options to treat calcaneal apophysitis, most of which mirror home treatments:
- Reduce or stop any activity that causes pain.
- Temporary shoe inserts, gel heel cups, or custom orthotic devices to provide support for the heel.
- Nonsterioidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to control the pain and inflammation.
- Stretching or physical therapy modalities to promote healing of the inflamed issue.
- In some severe cases of calcaneal apophysitis, the foot and ankle may require immobilization in a cast for 2-6 weeks, affording it a good chance to heal.
Surgical Treatments
Surgical treatments are not used or necessary to treat calcaneal apophysitis.
How to Prevent a Calcaneal Apophysitis?
A child can reduce the chance of developing a calcaneal apophysitis by:
- Avoiding obesity.
- Choosing well-constructed, supportive shoes appropriate for the activity, while avoiding or limiting the wearing of athletic shoes with cleats.
- Avoiding activity beyond the child’s ability.
- Wearing supportive, well-padded, shock-absorbing footwear that fit properly.
- Performing proper warm-up prior to any activity. Ten minutes of light jogging, cycling, or calisthenics beforehand will increase circulation to cold muscles, making them more pliable so they will put less stress and tension on the growth plates.
- Never playing through pain. Pain is a sign of overuse, stress, or injury. Rest is necessary to give body parts time to recuperate and heal.
- Stretch tight calf muscles several times a day. It is better to stretch after exercise. Hold each stretch for 30 seconds without bouncing. Some of the calf-stretching exercises a child can do include:
- Kiss the Wall. Standing about two feet from a wall. Flex the left foot and place it against the bottom of a wall. Keep your back tall and straight. Then, lean forward from the hips as if you were trying to kiss the wall. Repeat with the other leg.
- Standing Calf Stretch. Facing a wall, put hands against the wall at about eye level. Put one foot in front and keep the forward knee bent. With the back knee straight, push the heel of the back leg down on the floor and slowly lean into the wall until you can feel the back calf muscle stretch. Repeat with the back knee bent. Then, repeat both stretches with the other leg in front.
- Towel Stretch. Sit on the floor with the affect leg stretched out. Loop a towel around the ball of that foot and pull the towel toward the body. Keep the knee straight. Repeat for the other leg.
