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  • Writer's pictureDaniel Selin

Sever's disease

Heel pain, apophysitis, osteochondrosis, heel pain in children and adolescents, heel stress injury, overuse injury, tendon pain, growing pain, sports injury, growth plate injury.

Jalan tutkiminen

Sever's disease, also known as apophysitis or osteochondrosis of the growth plate located in the heel bone, is the most common cause of heel pain in children during their growing years. The condition typically presents as pain in the back of the heel, without a history of injury. The pain occurs as a result of repeated stress, such as jumping and running, which causes strain on the attachment point of the Achilles tendon and leads to discomfort.

Sports that involve a lot of running, jumping, and especially sprinting, such as soccer, floorball, basketball, and volleyball, are often associated with this condition. Rapid movements on hard surfaces, such as quick starts and stops, and changes in direction can exacerbate the problem. This may be one reason why apophysitis is becoming more common among young soccer players, as sand fields are being replaced by artificial turf, which allows for faster movements and higher impact on the attachment points.

On sand fields, players could slide when starting or stopping, which reduced the pulling force on the growth plates, as the kinetic energy dissipated in the sand. This reduced the risk of injury and the load on the tissues was not as high as it is now.

 

Apophysitis and osteochondrosis

Apophysitis refers to a situation in which the bone's growth area, apophysis, is subjected to repeated traction stress without adequate recovery. This leads to microscopic damage to the growth area, which over time can become more extensive and cause pain, swelling, and pressure sensitivity.


Apophysitis is a general term for pain at the attachment site of the growth area and the skeleton muscle and does not necessarily indicate an inflammatory condition, although the suffix "-itis" suggests this. Apophysitis can occur on any growth area, depending on the load generated by the sport in question. The most typical apophysitis is found in the knee and heel areas. Advanced apophysitis can lead to osteochondrosis.


Osteochondrosis is a more severe skeletal growth disorder than apophysitis, which may involve inflammation, a hardening or widening of the growth area, and bone necrosis. The cause is often a circulatory disorder in the bone or growth plate, resulting in local necrosis, although bone regeneration often follows.


The root cause of osteochondrosis is not known, but the same factors that cause apophysitis are often involved. Genetic factors and anatomical anomalies also contribute to the development of osteochondrosis. The most typical apophysitis and osteochondrosis are Osgood-Schlatter disease, Sever's disease, and Sinding-Larsen-Johansson disease.

 

Etiology

Sever's disease is a condition caused by overuse, resulting in apophysitis or osteochondrosis of the C-shaped growth plate located in the heel bone. The growth plate becomes overloaded and painful due to repeated pulling on the Achilles tendon. Sever's disease is most common in children aged 7-14, with boys being slightly more affected than girls. Girls may experience symptoms earlier than boys. Pain is often worst immediately after physical activity but can also be felt at rest if the condition persists. Toe raises and pressure on the heel exacerbate the pain. The heel is often tender to the touch and can cause changes in gait during walking or running. Sever's disease often affects both heels simultaneously.


Risk factors for the condition include reduced flexibility or relative weakness of the calf muscles, as well as biomechanical challenges in the lower leg. Increased overall stress, inadequate recovery, one-sided training, poor nutrition, or insufficient sleep can also contribute to the condition. Therefore, it is important to consider all relevant factors when assessing the condition to ensure effective and individualized treatment.

 

Risk factors

  • Gender: Boys are more likely to get injured than girls.

  • Age: Boys aged 10-14 and girls aged 7-12 are at a higher risk.

  • Sudden growth spurts can put stress on developing bones.

  • Repeated stress on the heels, such as jumping and running.

  • Insufficient recovery time.

  • Doing the same type of exercise for extended periods or specializing in a single sport too early.

  • Tightness in the Achilles tendon or limited ankle mobility.

  • Poorly cushioned or worn-out sports shoes.

  • Running on hard surfaces.

  • Being overweight.

 

Symptoms

During the early stages of Sever's disease, the symptoms often include pain after physical activity and a sensation of warmth around the heel bone area. Sometimes, the pain in the heel is also accompanied by discomfort or stiffness in the Achilles tendon or calf muscles. As the condition progresses, the pain may also occur during physical activity and even at rest. An enlarged bump may also develop due to increased pulling on the heel. The heel may be swollen and tender to the touch, causing changes in walking and running style. The child may start to limp and avoid unnecessary strain on their feet.

 

Treatment

In treating Sever's disease, it's crucial to stop painful exercise and get enough rest. Since exercise breaks can be long, lasting several months, it's important to find another type of physical activity that the young athlete enjoys and can participate in while their favorite sport is on hold. Additionally, it's a good idea to use this time to work on technique specific to the sport, which can improve skills without exacerbating heel pain.


Calf flexibility and elasticity can be improved through a light, progressive stretching routine and manual therapy. To reduce heel pressure, it's also important to wear shoes with soft soles and good cushioning, which minimize impact on the heel. Lower limb biomechanics and functional control should be improved in conjunction with strength training. Problems with hip and gluteal strength can cause knee collapse during squatting, altering foot position and potentially exacerbating heel pain.


During acute pain episodes, it's recommended to use cold therapy systematically. Careful consideration should also be given to footwear and equipment choices. In severe cases, the foot may need to be immobilized in a cast to allow the affected area to heal. Surgery may also be considered if other treatments fail to improve the condition, but it's typically reserved for cases where growth has already stopped. However, surgery is a rare treatment option, and the prognosis for recovery from Sever's disease is generally excellent.

 

Physiotherapy

Physiotherapy always begins with a thorough assessment of the background factors, in order to identify the causes of the problem and create a personalized rehabilitation program. The underlying factors must be distinguished from one another and it must be determined which factors have contributed to the onset of pain.

The assessment aims to find the reasons for the condition. Typically, these factors can be roughly divided into three groups:

  1. Too much stress or insufficient recovery

  2. Rapid growth spurts

  3. Biomechanical factors that lead to increased stress on the heel or Achilles tendon

With the help of a physiotherapist, faulty postures can be corrected through exercise therapy and custom orthotics. Movement restrictions in the ankle or foot can be addressed through mobilization techniques, and tight or sore muscles can be treated to prevent future stress on the heel.

Rehabilitation is always individually planned according to the patient's needs and background factors. What works for one person may not be the best treatment for another. Therefore, it is important to seek the help of a physiotherapist specializing in lower limb or youth overuse injuries as soon as possible.

 

Self care

Here are some specific exercises and tips that may be helpful for someone with Sever's disease:

  1. Rest: Avoid activities that exacerbate pain and inflammation. Resting the affected area may help reduce pain and promote healing.

  2. Ice therapy: Apply ice to the affected area for 15-20 minutes at a time, several times a day. This can help reduce pain and inflammation.

  3. Stretching: Gentle stretching exercises for the calf muscles can help reduce tension in the heel and improve flexibility.

  4. Strengthening exercises: Strengthening exercises for the calf muscles can help improve ankle stability, promote blood flow and reduce the risk of future injuries.

  5. Proper footwear: Wear shoes that provide good support and cushioning to reduce stress on the heel.

  6. Heel cups or pads: Using heel cups or pads can provide extra cushioning and support to the heel. They also help by minimising the pull on the achilles tendon as they lift the heel of the ground.

  7. Pain relief medication: Over-the-counter pain relief medication, such as ibuprofen or paracetamol, can help alleviate pain and reduce inflammation.

  8. Consult a physical therapist: If your pain persists despite self-care measures or is interfering with your daily activities, consult a physical therapist. hey may recommend additional treatments such as manual therapy, individualized exercise program or custom orthotics.

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