Sever's Disease

Sever's Disease

Sever's disease is mainly a cause of heel pain in kids affecting active children aged 8 to 15 years old. Pain at the back of the heel from overuse that if managed correctly, is something the young athlete should grow out of. Rest is an essential part of treatment along with ice or cold therapy and managing training loads.

Similar pain at the back of the heel in adults is more likely Insertional Achilles tendonitis.

Symptoms

The main symptom of Sever's disease is pain and tenderness at the back of the heel which is made worse with physical activity.  Tenderness will be felt especially if you press in or give the back of the heel a squeeze from the sides. There may be a lump over the painful area. Another sign is tight calf muscles resulting in reduced range of motion at the ankle. Pain may go away after a period of rest from sporting activities only to return when the young person goes back to training.

Causes

Severs disease is often associated with a rapid growth spurt. As the bones get longer, the muscles and tendons become tighter as they cannot keep up with the bone growth.

The point at which the Achilles tendon attaches to the heel becomes inflamed and the bone starts to crumble (a lot like Osgood Schlatter disease of the knee).

Tight calf muscles may contribute to the range of motion at the ankle is reduced resulting in more strain on the Achilles tendon. Sever's disease is the second most common injury of this type which is known as an apophysitis.

Premiership football physiotherapist Neal Reynolds talks about growing pains in children and the relationship to sever's disease

Treatment

The aim of treatment is to reduce the pain and inflammation when gently stretch the muscles. There is likely to be no magic instant cure and the young athlete may have to be patient while they grow.

Apply the PRICE principles of protection, rest, ice, compression, and elevation. Rest from any activity which makes the injury worse. Initially, certainly the first 48 to 72 hours this will mean complete rest. Later on when normal daily activities can be done pain-free then modifying training to avoid certain activities which increase pain should be done. This is likely to include running, jumping and any sports which involve this kind of weight bearing, high impact activity. It may be necessary to stick to swimming or cycling until the injury has completely cleared up.

Apply ice or cold therapy for 10 mins every hour initially, reducing the frequency as symptoms improve. Do not apply ice directly to the skin but wrap in a wet tea towel or better still use a cold therapy and compression wrap. Insert a heel pad or heel raise into the shoes. This has the effect of raising the heel and shortening the calf muscles and so taking the strain off the back of the heel. However, the long-term use of a heal raise may shorten the calf muscles when they need stretching

A doctor or physiotherapist can apply a plaster cast or boot if the child is in severe pain. This may be worn for a few days or even weeks and should give relief of pain for a while. The will carry out a full biomechanical assessment to help to determine if any foot biomechanics issues are contributing to the condition. Orthotics or insoles can be prescribed to help correct overpronation or other biomechanics issues.

They may prescribe anti-inflammatory medication such as ibuprofen to reduce pain and inflammation. This will not be prescribed if asthma the child has asthma. In persistent cases, X-rays may be taken but this is not usual. A sports injury professional will NOT give a steroid injection or operate as these are not suitable treatment options. The condition will usually settle within 6 months, although it can persist for longer.

Below is an outline example of a rehabilitation program which may be used for young athletes suffering from Sever's Disease.  We advise seeking professional advice before commencing a rehabilitation programme.

Stage 1: Reducing heel pain and inflammation

  • Rest until the pain has gone. If you continue to train on it when it is inflamed and painful you will make it worse, possibly even cause more permanent damage to the bone.
  • Apply cold therapy. This can be in the form of ice. Massage an ice cube or similar over the site of pain. Ice can be applied for 10 to 15 minutes every two hours depending on the severity of the pain.
  • Put a 1cm heel raise in the shoes to help take the pressure off the heel. If the Achilles tendon is shortened via the heel raise then it will not be pulling quite so much on the back of the heel. However this is only done for a short period in conjunction with rest. If the Achilles tendon adaptively shortens over time then this may cause other problems.

Stage 2: Stretching the muscles of the lower leg

  • This should only be done if the foot is free from pain. This may be a couple of days, it may be longer. Let pain be the guide rather than following strict time limits.
  • The athlete should continue to rest from exercise.
  • There are two stretches that are important, one with a straight leg and the other with the knee bent. This allows both the Gastrocnemius muscle and Soleus muscles to be stretched.

Stage 3: Gradual return to exercise and strengthening

  • The muscles of the lower leg should be strengthened as well as stretched. Again, exercises should only be done pain free.
  • Concentrate on stretching until full range of motion has been reached. Then gradually build the strength into the lower leg with strengthening exercises.

Exercises

Stretch the calf muscles regularly. Stretching should be done pain-free and very gently with this injury. Sports massage can help improve the condition of the soft tissue and joint flexibility. Strengthening exercises are not usually recommended for treating Servers disease as it is an overuse injury and requires rest. When returning to sport the load through the tendon should be gradually increased. Do not go straight back to full training or the injury may recur.

The following guidelines are for information purposes only. We recommend seeking professional advice before beginning rehabilitation.

Testing Flexibility

  • Stretching should only be done if the foot is free from pain. It is important to stretch the muscles especially if they are particularly tight as this will be extra strain on the point of injury.

  • Image shows how to test the calf muscles and gastrocnemius in particular are too tight. By gently pushing on the toes, the foot should go to 90 degrees without having to force it or apply great pressure. If the foot does not go to 90 degrees this may indicate excess tension in the muscles.
  • By bending the knee the gastrocnemius muscle is shortened leaving the soleus muscle stretched. Again, this should comfortably go to 90 degrees.

There are two stretches that are important when stretching calf muscles. The first one is done with the leg kept straight which stretches the Gastrocnemius muscle. This muscle starts above the knee and enters the back of the heel via the Achilles tendon. The other is the Soleus muscle which starts below the knee. By bending the knee we relax the Gastrocnemius muscle, so allowing the Soleus to take the stretch.

Active stretching

  • This type of stretching will be the safest to use in the early stages of rehabilitation (image 3). It involves pulling the foot and toes up gently to stretch the muscles at the back of the leg.
  • Hold for 8 seconds, repeat 5 times. Stretch if pain allows throughout the day.

Gastrocnemius stretch

  • Keep the heel of the back leg on the ground and gently push forward (image 4). If it is painful do not do it. This will stretch the larger Gastrocnemius muscle which attaches above the knee.

  • This stretch can be held for at least 10 seconds and repeat 3 times. This set of stretching can be done three times a day - more as long as it does not hurt. Some therapists will recommend holding stretches for longer periods of up to 45 seconds.

Soleus muscle stretch

  • By bending the knee, the Gastrocnemius muscle is taken out of the stretch allowing the Soleus muscle to be stretched further down the leg. If it hurts, do not do it.
  • You should hold this stretch for at least 10 seconds and repeat 3 times. This set of stretching can be done three times a day - more as long as it does not hurt.
  • The above stretches are all that need to be done for the Achilles and calf muscles. It is the quality of what you do rather than the quantity. Remember that stretching is a long term process.
  • Results may not be evident for a few days or even weeks. It is also important to maintain a stretching routine even after the injury has healed.
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