Sever's Disease Classic Presentation
Calcaneal apophysitis (also known as heel growth plate pain) is an injury specific to pediatric athletes, usually in the age range of 7 to 12 years. Athletes will usually complain of heel pain at the end of a practice or end of a school day. Pain typically will resolve with rest. However, more severe cases can be painful enough to cause a limp. Also, pain can be ongoing for weeks to months prior to seeking care, due to instances where pain resolves with rest.
General Evaluation
The athlete will typically have no notable swelling of the foot or ankle. Tenderness with deep pressure over the inner and outer aspect of the heel is the most common finding. This is called the calcaneal squeeze test and can be seen below. Keep in mind that there is an area of fat on the bottom of the heel that can mask the area of pain when pressure is applied. Calcaneal apophysitis can be confused with plantar fasciitis, which is typically more common in older patients. In general, x-rays are not needed, but in the photo below you will see the presence of the calcaneal growth plate that is sometimes confused for a fracture. The whiter appearance to the growth plate compared to the rest of the foot can be indicative of Sever's disease, however, fragmentation of the growth plate is usually normal.
Calcaneal Squeeze Test
Sample X-ray 11-year-old male
Treatment
In general, Sever's Disease or calcaneal apophysitis will improve over time, although athletes can see flare-ups depending upon their volume of activity. The flare-ups should subside once the growth plate in the heel has closed. Relative rest and icing is a good first step when in pain. Stretching and improving flexibility of the calf muscles can be helpful to prevent return of pain once it is under control. Another option of treatment is a heel cup that can be worn in the shoe or cleat to help cushion the area. I have seen good success with the Tuli's Heel Cups pictured below. Other options for shoe inserts include gel heel cups, but my experience is that they do not work as well as the Tuli's brand. Another suggestion I give is to have the athlete do any conditioning they can in a comfortable running shoe rather than cleats.
Tuli'S Heel Cups
Cheetah Heel Cups
Return to Play
Mild calcaneal apophysitis does not require restriction from activities, as the athlete can usually participate on an as tolerated basis. Moderate pain may require restriction from activities for several weeks to a month, until the pain is better under control and flexibility of the calf muscles have improved. In rare cases, the athlete may need to be placed in a boot and crutches to completely remove weight from the heel and allow it to heal appropriately. Athletes whose sport require them to participate bare-footed, such as gymnastics or martial arts, may be more at risk and should consider using Cheetah Heel Cups. Also, an athlete should consider cross-training and conditioning in a sport with less impact, such as swimming or biking.