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Calcaneal apophysitis, also known as Sever disease, is the painful inflammation of the apophysis of the calcaneus.
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It typically presents in active young children and adolescents, especially those who enjoy jumping and running sports.
High plantar foot pressures are associated with Sever disease, although it is unclear whether they are a predisposing factor or a result of the condition. Gastrocnemius equinus may be a predisposing factor for Sever disease 7.
Patients tend to present with posterior heel pain, usually aggravated by physical activity such as walking, running, or jumping.
The condition is thought to result from repetitive microtrauma to growth plates of the calcaneus. However, some of the recent literature states that there is a lack of evidence that weight and activity levels are risk factors for Sever disease 6.
Sever disease is most often diagnosed clinically, and radiographic evaluation is believed to be unnecessary by many physicians, but if a diagnosis of calcaneal apophysitis is made without obtaining radiographs, a lesion requiring more aggressive treatment could be missed 4.
Foot radiographs are usually normal and the radiological identification without clinical information is not reliable 9. When present, the radiological signs, albeit nonspecific, are:
increase in the density of the calcaneal epiphysis
fragmentation of the epiphysis
If unilateral may show asymmetrical thickening and in some cases may be associated with a retrocalcaneal bursitis 12. Fragmentation of the apophysis (with a saw teeth appearance) may be visible on ultrasound at times.
MRI is considered most accurate imaging examination method in assessing damage of the epiphysis 13. May show edematous changes within the calcaneal apophysis, possibly extending into the adjacent calcaneal tuberosity 10. MRI may also show a retrocalcaneal bursal effusion 13.
Treatment and prognosis
The condition is self-limiting with a brief limitation of activity sometimes being advocated. Standard advice is to reduce physical activity 8.
History and etymology
It is named after James Warren Sever (1878-1964), an American orthopedic surgeon, who first described it in 1912 1,11.
- 1. Sever JW: Apophysitis of the Os Calcis. New York Medical Journal 1912; 95: 1025-1029.
- 2. Beck L, Heindel WL. [Apophysitis calcanei]. Rofo. 2012;184 (11): 973-5. doi:10.1055/s-0032-1318952 - Pubmed citation
- 3. Tu P, Bytomski JR. Diagnosis of heel pain. Am Fam Physician. 2011;84 (8): 909-16. Pubmed citation
- 4. Rachel JN, Williams JB, Sawyer JR et-al. Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (sever disease)?. J Pediatr Orthop. 2011;31 (5): 548-50. doi:10.1097/BPO.0b013e318219905c - Pubmed citation
- 5. Volpon JB, De Carvalho Filho G. Calcaneal apophysitis: a quantitative radiographic evaluation of the secondary ossification center. Arch Orthop Trauma Surg. 2002;122 (6): 338-41. doi:10.1007/s00402-002-0410-y - Pubmed citation
- 6. Scharfbillig RW, Jones S, Scutter S. Sever's disease: a prospective study of risk factors. J Am Podiatr Med Assoc. 2011;101 (2): 133-45. Pubmed citation
- 7. Becerro De Bengoa Vallejo R, Losa Iglesias ME, RodríGuez Sanz D et-al. Plantar pressures in children with and without sever's disease. J Am Podiatr Med Assoc. 2011;101 (1): 17-24. Pubmed citation
- 8. Perhamre S, Lundin F, Norlin R et-al. Sever's injury; treat it with a heel cup: a randomized, crossover study with two insole alternatives. Scand J Med Sci Sports. 2011;21 (6): e42-7. Scand J Med Sci Sports (full text) - doi:10.1111/j.1600-0838.2010.01140.x - Pubmed citation
- 9. Kose O, Celiktas M, Yigit S et-al. Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever's disease)?. J Pediatr Orthop B. 2010;19 (5): 396-8. doi:10.1097/BPB.0b013e32833a5fa7 - Pubmed citation
- 10. Lawrence DA, Rolen MF, Morshed KA et-al. MRI of heel pain. AJR Am J Roentgenol. 2013;200 (4): 845-55. doi:10.2214/AJR.12.8824 - Pubmed citation
- 11. Obituary. N Engl J Med. 1964;271:475.
- 12. Hoşgören B, Köktener A, Dilmen G. Ultrasonography of the calcaneus in Sever's disease. (2005) Indian pediatrics. 42 (8): 801-3. Pubmed
- 13. Gao Y, Liu J, Li Y, Liu Q, Xu S. Radiographic Study of Sever's Disease. Exp Ther Med. 2020;20(2):933-7. doi:10.3892/etm.2020.8796 - Pubmed
- Radiographic study of Sever' s diseaseExp Ther Med. 2020 Aug; 20(2): 933–937. Published online 2020 May 26. doi: 10.3892/etm.2020.8796 PMCID: PMC7388271 PMID: 32742336 Yan Gao,1 Jia Liu,2 Yifang Li,2 Qing Liu,2 and Shuhua Xu1 1Department of Radiology, People's Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China 2MRI Room, People's Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China Correspondence to: Dr Yifang Li, MRI Room, People's Hospital of Rizhao, 126 Tai'an Road, Rizhao, Shandong 276800, P.R. China [email protected]