Debby Yagoudaef

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How To Diagnose Calcaneal Apophysitis?

Overview

Sever's Disease is one of the most common causes of heel pain in active adolescents. Hip stability is restored using a non-surgical positioning device. Symptoms of Sever's disease are relieved through a combination of conservative treatment options and preventative measures can be taken to decrease the risk of developing the condition.

Causes

The calcaneal apophysis develops as an independent center of ossification (possibly multiple). It appears in boys aged 9-10 years and fuses by age 17 years, it appears in girls at slightly younger ages. During the rapid growth surrounding puberty, the apophyseal line appears to be weakened further because of increased fragile calcified cartilage. Microfractures are believed to occur because of shear stress leading to the normal progression of fracture healing. This theory explains the clinical picture and the radiographic appearance of resorption, fragmentation, and increased sclerosis leading to eventual union. The radiographs showing fragmentation of the apophysis are not diagnostic, because multiple centers of ossification may exist in the normal apophysis, as noted. However, the degree of involvement in children displaying the clinical symptoms of Sever disease appears to be more pronounced. In a study of 56 male students from a soccer academy, of whom 28 had Sever disease and 28 were healthy control subjects, findings suggested that higher heel plantar pressures under dynamic and static conditions were associated with Sever disease, though it was not established whether the elevated pressures predisposed to or resulted from the disease. Gastrocnemius ankle equinus also appeared to be a predisposing factor.

Symptoms

Symptoms of Sever?s disease, mostly pain at the back of heel, usually occur during and after sporting activity, and usually disappear with rest. In some cases, children may find it difficult to place pressure on their heels, and begin walking on their toes to gain relief. For some children, the heel pain will persist until the next morning, causing some stiffness or hobbling on first arising. Some children may experience mild swelling at the back of the heel.

Diagnosis

Physical examination varies depending on the severity and length of involvement. Bilateral involvement is present in approximately 60% of cases. Most patients experience pain with deep palpation at the Achilles insertion and pain when performing active toe raises. Forced dorsiflexion of the ankle also proves uncomfortable and is relieved with passive equinus positioning. Swelling may be present but usually is mild. In long-standing cases, the child may have calcaneal enlargement.

Non Surgical Treatment

Treatment of Severs disease usually involves a combination of an accurate analysis of your child?s gait, muscles, tendons, ligaments and joints is a crucial first step. Specific stretching and strengthening exercises often make up part of the treatment. Anti-inflammatory measures such as ice baths after exercise can be helpful in the short term. Footwear review, assessment and advice is important. Orthotic devices are often needed to firstly control any abnormal traction or tension on the heel growth plate and, secondly, too unload the ground reaction forces on the heel bone. Podiatry Care has podiatrists with specific paediatric training enabling them to utilise treatment options to relieve heel pain in children very quickly. If your child is struggling to play sport, see a Podiatry Care podiatrist near you. In severe cases modification to activity levels may be required. Treatment of Severs disease does NOT require surgery. This foot condition responds very well to conservative treatment.

Prevention

It is important to undertake correct warm ups and warm downs before and after exercise. This should include a stretching routine. It may be necessary to undertake additional stretching outside of sport, especially during stages of growth. Only playing one sport should be avoided. You should not allow your child to play through pain.
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