Growth Related Injury Series: Severs Disease

Hosted by: Tara Christensen PT, MS, DPT

In this episode:

In this first episode of a series on growth related injuries, Dr. Tara outlines what parents should know about Sever’s Disease.

References:

Hernandez-Lucas, Pablo, Leiros-Rodrigues, Raquel, Garcia-Lineira, Jesus, Diaz-Buil, Helena.  “Conservative Treatment of Sever’s Disease: A Systematic Review”.  Journal of Clinical Medicine. 2024, 13, 1391.  Https://doi.org/10.3390/jcm13051391

Nieto-Gil, Pilar et al., “Risk factors and associated factors for Calcaneal apophysitis (Sever’s disease): a systematic review”.  BMJ Open 2023, 13:e064903. Doi:10.1136/bmjopen-2022-064903

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Transcript

SPEAKER_00 0:01

Welcome to the Dr. Dance Mom Podcast, your guide to strong dancers with a bright future. I'm your host, Dr. Tara Christensen, Doctor of Physical Therapy, Dance Medicine Specialist, and Proud Dance Mom. Let's dive into today's episode. The information presented in this podcast is for educational purposes only and does not constitute medical advice. Listening to this podcast does not create a healthcare provider patient relationship. Always seek the advice of a qualified healthcare professional regarding any medical conditions or treatment. Hello, everyone, and welcome back to the Dr. Dance Mom podcast. I'm your host, Dr. Tara Christensen. I've been on a little bit of a hiatus for a couple of weeks, so I apologize. But things have been a little bit busy over here. It's the middle of competition season. I do have a daughter who's a competitive dancer, so things have been a little bit crazy with competitions. We had two uh weekends back to back where she was competing. Um, and so just trying to recover um in between competitions, get back to sort of normal baseline. Um, I do have another daughter as well, and then you know, I I work a part-time job and have a business, so things can be a little crazy at times, but I love providing tidbits of education, just be super patient with me over the next couple of months. I also have something really exciting coming up in my business. So there's some really big things happening that I'm super excited to talk about once things are ready to speak on and come to fruition a little bit more. So stay tuned for that. In the meantime, it may be a little bit more sporadic in terms of you know recording and putting out episodes until I can kind of return to a normal baseline, whatever that is. Um, I think it's all relative at this point. But certainly the next couple of months, I won't have quite as much time on my hands. So I hope to be able to continue putting episodes out, but it may just be a little bit more sporadic than it has been. Today, what I really want to talk about is um a condition called Sever's disease. And so I had this idea after my last episode. I really wanted to talk about different growth-related injuries and syndromes that dancers and other youth athletes sometimes run into. I do think it's important that parents understand what these different conditions look like, um, what they mean, so that when you go to maybe an orthopedist and your child is diagnosed with one of these things, you kind of have a better understanding of what it is to begin with. And you may also have a better understanding of what their recovery time might look like as well, um, just by being armed with some information. I'm just one of those people that really believes that knowledge is power. I think in today's landscape in terms of medicine, as parents, we definitely have to arm ourselves with knowledge so that we can be good advocates for our children. And so that's what I hope to accomplish with these next few episodes. I have already released some newsletters on these topics in my business newsletter. So if you follow along there, this will be a lot of repetition because it's pretty much the same information, but in just a different media format. So let's talk a bit about Severs disease. Um, Severs disease is the common name for a condition called calcaneal apophysitis. Oh, there's some big words. It is basically an irritation of the growth plate in the heel, and it is the most common cause of heel pain in children and young people, and accounts for 5.8 to 22.7 of repetitive stress injuries in children. I know those are very specific numbers, but that is what the research tells us. It is most common in girls between 7 and 12 years of age and boys between 8 and 15 years of age. In general, it peaks between about 10 and 12 years of age. And the reason for those age ranges is because that's typically the times where each of those genders is undergoing the most rapid period of growth. It was first described in 1912 by Dr. Sever, which is where the name comes from, obviously. Calcaneal apophysitis is inflammation or bone edema due to stress in the growth plate of the heel bone or the calcaneus. That is the scientific term for the heel bone. The inflammation occurs due to traction forces from your calf muscle on the growth plate. It typically occurs during periods of growth or growth spurts. So athletes are at an increased risk for the condition when they're in an active growth phase due to ground reaction forces. Anyone who does any sort of running, jumping, kind of high impact type activity would be more at risk for this. As the child grows, the growth plate is open, but eventually is replaced by solid bone once full maturation occurs. So that's kind of how growth will occur. Until then, the growth plate is weaker than the ligaments and the tendons around it. So that is why the growth plate is typically what gets irritated in children, just because the tissues that kind of attach in and around that growth plate are a bit stronger than the growth plate itself. The repetition of traction forces combined with the ground reaction force on the calcaneus causes bending forces on the inside of the egg growth plate or the medial side. So um, and that's traction forces that are imposed by the calf muscle as it contracts forcefully due to landings. Another cause can be overuse due to repetitive impacts that generate repetitive micro trauma and movements like running or jumping. This is, I think, where we see more of it in the dance space. It can be worsened by inadequate footwear or footwear that doesn't have enough cushioning. And so we know for dancers, depending on what styles of dance they're doing, you know, ballet shoes typically don't have much cushion, neither do jazz shoes. Um, styles like modern and contemporary and sometimes acro are done barefoot. So there's really no footwear and definitely no cushioning. So all of that repetitive trauma to and around the growth plate just from all of that impact is typically what will cause the condition. Overtraining, um, sports plate on hard surfaces. So again, if we think of the dance studio floor, um, especially things like acro movements, if there are acro movements in a routine that's being rehearsed in the regular dance studio floor, not on mats, obviously it's being performed on a stage without mats typically in competition. So a lot of those things can kind of provoke this condition at times. Severs usually is a unilateral condition, so that means it occurs on one side. Diagnosis is made typically based on signs and symptoms, but can be confirmed with x-rays. Symptoms to watch out for are pain and tenderness underneath the heel or in the back of the heel, but typically not in the Achilles tendon or in the plantar fascia, so the structures in the bottom of the foot. So it's really kind of on the edge of the heel or the back of the heel. Swelling in that area as well. Um, pain when you squeeze the heel or put weight on it, and stiffness in the heel area after sleeping. So those are all signs to watch out for. Pain is typically worse in shoes without a heel or when barefoot. So those are two conditions that will typically make them feel worse. So there are a couple of intrinsic and extrinsic factors that will contribute to several disease. Uh, the first one is limited ankle dorsiflexion, and ankle dorsiflexion is um just the ability to kind of lift the foot off the ground. So if you put your foot flat on the floor and lift your your toes or your foot um off the ground with your heels still on the floor, that would be that's ankle dorsiflexion. So if that's limited at all, then that could contribute to sever's. Others are alterations in foot alignment. So if they have different foot posture, then what would be considered to be normal, then that might contribute as well. Um Oshgoodschlauder disease is also considered a factor. They Osgoodschlader is another growth-related syndrome that occurs at the knee, which I'll talk about in the next episode. And in the literature, the two are very closely associated in terms of not a causal relationship, but if a child develops one, they have an increased likelihood to develop the other. Flat feet is another factor. Um, having a club foot would be another one. Higher BMI or increased weight would be a factor, and increased height. So a child that's a little bit taller, probably because they've had larger growth spurts. Treatments can include things like stretching and lengthening of the calf muscle complex, ice when the child is having symptoms, restriction or limitation of their activity level, and rest. Wearing shoes with a slightly elevated heel to accommodate the shortened calf muscle may also be helpful. In some cases, they may need to wear a boot to immobilize for a little bit just to allow that inflammation to settle or take some NSAIDs. Taping is another option, use of heel cushions, orthopedic insules, and physical therapy. One of the studies that I came across did not mention physical therapy at all. Um, and a lot of the resources I found online also don't mention physical therapy as a treatment method, but sight, rest, ice, and stretching as a recommended treatment. But um, what I found really interesting here is based on my own experience and working with children with severs, physical therapy is a super, super effective way to manage it. Um I have had a couple instances where I've run into um dancers who had a diagnosis of severs. I had one in particular who had had pain for quite a while, I think over a year, and had actually done a round of physical therapy elsewhere and immediately after was not any better. So they came to see me and within one or two treatments, they were dancing pain-free for the first time in over a year. And I'm not saying that because I'm like the most special or amazing physical therapist on the planet. Um, I'm just saying that to illustrate that, you know, it does require a very specific treatment approach. Not everyone's gonna respond that quickly, um, but there are therapists out there that can help to manage those symptoms so that you don't have as much lost time in the sport. Um, I think it also helps that I work with dancers, I understand the demands that are placed on a dancer's body, I understand what they're doing in class. And so we were very quickly able to identify what the main issues were. Um, and especially with dancers who are, you know, constantly on releve if they're taking ballet, if they're taking jazz, and really kind of managing the load on that um growth plate and being able to give them a proper return to sports plan. For a lot of people, this says rest might be required for several months. I'm sure that that is the case in some severe cases. I have not come across a child who has needed that much rest. Um, I think an active approach, again, to rehab has been really successful, at least with the patients that I've seen with severs. And one of the sources cited return to play in two to eight weeks. I think that's pretty accurate. It really depends on the severity of the inflammation and the severity of symptoms that the child is experiencing. And that kind of wraps up the basic information on Severs disease. If you guys have any questions specifically about Severs, or if there are any other diagnoses that you would love to see me cover, please note them in the comments, send me an email. We would I would love to kind of dive into any topic area that you guys want me to speak on. I think, again, arming yourself with knowledge on some of these diagnoses, some of these topics that can affect your child is the truly the best way to be able to advocate well for your child. I hope you enjoyed today's episode and learned something. Please be sure to follow or subscribe so you don't miss a thing. Also make sure you head over to Instagram and YouTube and follow us there. Send us your listener questions, topic suggestions, and feedback at drdancepodcast at female.com. That's dr fully written out.com. Thanks so much for listening.