Calcaneal apophysitis

Last revised by Rohit Sharma on 20 May 2024

Calcaneal apophysitis, also known as Sever disease, is the painful inflammation of the apophysis of the calcaneus.

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 the growth plates of the calcaneus. However, some 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 apophysis

  • fragmentation of the apophysis

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 apophysis 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.

The condition is self-limiting with a brief limitation of activity sometimes being advocated. Standard advice is to reduce physical activity 8.

It is named after James Warren Sever (1878-1964), an American orthopedic surgeon, who first described it in 1912 1,11.

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