CASE 9398 Published on 22.06.2011

Sever’s disease

Section

Musculoskeletal system

Case Type

Clinical Cases

Authors

Perdikakis E, Ntitsias T, Petkidis I
Dpt of Radiology, 412 General Military Hospital, Greece

Patient

8 years, male

Categories
Area of Interest Extremities, Musculoskeletal system ; Imaging Technique Ultrasound, Conventional radiography, Ultrasound-Colour Doppler
Clinical History
An 8-year-old boy, an elite soccer player, presented with a five-week localised pain in the posterior aspect of the left foot. The pain worsened with training and excluded prompt return to sports activity. The medical history did not reveal any recent or remote injury of the foot.
Imaging Findings
Physical examination revealed mild swelling and tenderness on palpation over the posterior left heel (Fig. 1). No restriction in the range of motion was noticed. An ultrasound examination was performed upon request that demonstrated fragmentation of the apophysis of the calcaneus and an avulsed bony fragment at the insertion of the Achilles tendon (Fig. 2-3). Plain radiographs were performed subsequently and verified the ultrasonographic findings (Fig. 4). The patient’s clinical history, the overuse of sports activity (elite soccer player), together with the imaging findings established the diagnosis of a traction calcaneal apophysitis (Sever’s disease) and the patient was treated with rest, heel raise shoe orthoses and sports restriction to be applied for 6 weeks. The athlete was allowed to return to full sport activities six weeks post heel raise shoe orthoses removal.
Discussion
Sever’s disease (apophysitis calcanii) is an overuse injury that is caused by repetitive microtrauma due to increased traction of the achilles tendon upon the calcaneal apophysis [1-3]. Literature reports show that calcaneal apophysitis comprises 2%-16% of musculoskeletal injuries in children [1-3].This overuse avulsion injury is characterised by localised posterior heel pain that is exacerbated by motion. The patients experience this painful condition near the lower posterior calcaneal aspect, at the attachment of the achilles tendon into the secondary growth plate of the calcaneus [1-3]. The calcaneal growth centre appears at approximately seven years of age and fuses between thirteen to fifteen years. Hence posterior heel pain is typically observed in pre-adolescent and adolescent children. Due to the fact that skeletal muscles and achilles tendons are more resistant to stress than the calcaneal apophyseal growth plates, repetitive microtrauma or macrotrauma may result in the aforementioned painful overuse syndrome and avulsion injury that are unique for the paediatric athlete and are not observed in adults [1-4]. The delayed maturation and the normal fragmentation of the secondary growth centre, especially in adolescent boys, should not be confused, however, with traction apophysitis or avulsion fracture in the absence of clinical symptoms. The differentiation of these normal variants (non fused/fragmented secondary ossification center) from an overuse avulsion injury should be based on the clinical history - physical examination and the most reliable X-ray findings are the sclerosis and fragmentation of the apophysis [1-5]. The management of Sever’s disease remains a controversial issue [1, 3-6]. The recommended treatment options include: a) rest-cessation of sport activities, b) use of heel lifts or shoe orthoses, c) physiotherapy, d) oral or local analgesics, e) cast immobilisation and crutches with strict weight-bearing restriction and f) removal of the apophysis in cases of conservative treatment failure. What makes our case interesting is that, to the best of our knowledge, there is limited literature data regarding the sonographic evaluation of this apophyseal injury. In routine paediatric sports imaging, the high-frequency and high-resolution ultrasonography of musculoskeletal anatomy is fast, accurate, relatively inexpensive, widely available and allows dynamic evaluation of the ligamentous, muscular and tendinous structures permitting thus clinical correlation of symptoms and signs. The role of ultrasound in assessing musculoskeletal injuries is also accentuated by the fact that it carries no radiation-risk, which is of paramount importance especially in the paediatric population [7-8].
Differential Diagnosis List
Sever’s disease (apophysitis calcanii)
Non-fused secondary ossification centre
Normal fragmentation of the secondary ossification center
Final Diagnosis
Sever’s disease (apophysitis calcanii)
Case information
URL: https://www.eurorad.org/case/9398
DOI: 10.1594/EURORAD/CASE.9398
ISSN: 1563-4086