With a steady increase in the number of youth athletes training with us, I want to focus on a specific growth plate pathology that is common in growing, active adolescents. The growth plate pathology I’m talking about is Sever’s Disease.
So What is Sever’s Disease?
First off, I want you to understand that this is not a disease. It’s just named after the individual that first discovered it. It’s referred to as Severs disease or Calcaneal Apophysitis. This apophysitis is a bone disorder that results from swelling of the growth plate in the heel (calcaneus). A growth plate is an area at the end of a growing bone where cartilage cells (chondrocytes) change into bone cells (osteocytes) as we age.
Severs disease is common in growing, active kids. The rapid growth of adolescents between the ages of 8-13 for girls and 10-15 for boys is when this can occur. The pain in the heel usually stops around 15 or 16 because the growth plate at the calcaneus hardens and the growing bone fuses into mature bone.
What Are The Causes of Sever’s Disease?
As we Grow, sometimes our bones grow faster than muscles and tendons. When this happens, the muscles and tendons become very tight putting pressure on the growth plate at the heel causing pain and inflammation. In Calcaneal Apophysitis, repeated stress, overuse and micro trauma will cause the achilles tendon to pull on the calcaneus, leading to pain, swelling and tenderness.
Physical Activitiesthat involve a ton of running and jumping on hard surfaces can be the stresses that cause this pain. Sports such as basketball, track and gymnastics can all play a role on this disease. Also, standing too long in poor shoes can increase the chances of this heel pain.
Overpronationof the foot can also lead to an increased risk for developing Sever’s disease due to the stress that it puts on the achilles tendon and calcaneus.
Pre-Screening for Athletes with Sever’s Disease
The first step in the treatment of an athlete with Sever’s is gait pattern (walking mechanics) analysis to understand if there are any abnormalities in their mechanics. Specific interest is directed towards analysis of ankle/foot mechanics to identify if any overpronation is occurring.
We are also focusing our attention at the arch of the foot to ensure the foot is not flat or excessively arched, both of which can increase stress on the achilles and calcaneus.
Lastly, there may be leg length discrepancies within individuals who have Sever’s, which may attribute to overponation, poor foot arch, or increased stress on the achilles and calcaneus. This first step in the assessment of an athlete can help establish how to best approach a program geared towards the athlete.
Evidence-Based Strategies for Treatment of Sever’s Disease
Foot orthotics can help to pad the calcaneus to improve force absorption, decrease pain, reduce leg length discrepancies, improve arch support, and reduce overpronation. Personalized foot orthotics that are custom molded to the individual have been proven to reduce pain in sporting activities. Specifically, an orthotic with a heel cup and medial arch support is the most effective to manage Severe’s pain. While foot orthotics are a great way to manage pain in athletes, it should be considered a temporary fix since it will not address the underlying issue.
The way you walk is important in determining if this is causing your heel pain. If you overpronate, your ankle rolls inward pulling the achilles tendon which will pull on the calcaneus causing pain. Finding a shoe that prevents excessive Pronation or getting fit for customized orthotics may help. In our initial pre-screening protocol, video analysis is taken on their gait patterns. This allows me to see their walking patterns in which I can recommend a specific type of shoe that may help their gait or suggest they see an orthopedist for a custom orthodic.
Leg Length Discrepancies/Disparities:
A leg length discrepancy is anatomical which there may be need for inserts. A leg length disparity may come directly from the pelvis, changing the gait pattern and putting excess stress and tension on the achilles tendon causing pain. If your leg length discrepancy is anatomical, then placing an insert or custom orthotic in one shoe may help even out your gait cycle and decrease pain. If there’s a leg length disparity, meaning there is some deviation in the pelvis, then specific exercises are needed to correct this imbalance.
Kinesiology tape (K-Tape) and other taping methods to improve support of the ankle and achilles tendon have been found to have some benefits for improving pain perception acutely in athletes. This is a good way to temporarily decrease pain perception during sporting events and competition in athletes but, similarly to orthotics, will not fix the underlying issue.
Soft Tissue & Mobility Exercises:
Pain felt in the heel region is due to the pull of the achilles tendon on its insertion point on the calcaneus. Therefore, mobility and soft tissue work that focuses on relieving muscle tightness and reducing the pull of the muscles on the achilles tendon is important to help relieve pain. Foam rolling, lacrosse ball soft tissue work, and calf stretches are all great exercises to improve mobility of the calf muscles. Different stretching techniques including static, dynamic, proprioceptive neuromuscular facilitation (PNF), and much more can be utilized.
While strength exercises should aim at improving arch support of the foot and enhancing strength of the musculature that surrounds the ankle, exercises that incorporate all the muscles of the leg should be implemented. Overpronation, poor arch support, and other biomechanical abnormalities that lead to calcaneus pain can be a result of poor strength in the muscles surrounding the knees and hips. All lower body movement patterns such as multi-directional lunges, hip hinges, and squats should be implemented as tolerable by the athlete.
Management: Stretch, Soft Tissue & Strengthen
Besides REST, Stretching, Soft Tissue Work & Strengthening are the three S’s that can help alleviate the symptoms of Sever’s Disease. Before you strengthen, you must stretch and utilize soft tissue techniques to loosen the tissue around the bone. This will take pressure off the bony structure and allow for more efficient movement at the joint…without any restrictions, tightness or pulling.
If you strengthen before stretching/soft tissue work, there will be more tightness and pressure, leading to more pulling and more pain! Let’s look at a few stretching, soft tissue and strengthening exercises.
Soft Tissue & Stretching
This is where the athlete uses a foam roller, lax ball, stick or manual soft tissue therapy to loosen up the muscular tissue so that the joint can move a lot more freely, without irritation.
Athletes with Sever’s Disease will be limited in the amount of running and jumping they do. This means we can really crank on core musculature, balance and upper body anterior and posterior strengthening until their symptoms dissipate.