Sever’s syndrome is a pain in the heel for young athletes

seversWBy Kimberly Marselas

At the height of soccer season, Dr. Adrienne Spirt sees up to five patients a week with the same symptoms: a throbbing pain in the heel and tightness through the calf muscle. Based on her patient's age, Spirt can often diagnose the problem within a few minutes: Sever's syndrome.

Sever's (pronounced See-vers) is a temporary but often painful disorder resulting from inflammation of the heel. It usually strikes children between the ages of 8 and 13, while their growth plate is still developing and cartilage is calcifying into bone. Active children, like those involved in running-dominated sports like soccer, field hockey and lacrosse, are especially prone.

"Most of the kids who develop this are playing sports," says Spirt, an orthopedic surgeon specializing in foot and ankle problems at the Orthopaedic and Sports Medicine Center at Anne Arundel Medical Center. "Usually it will resolve itself in two to three months, but it's not uncommon to have a reoccurrence in the future."

Major contributing factors are repetitive use, obesity, a tendency to pronate or roll the foot inward when walking, and flat arches. Some doctors say the number of Sever's cases is increasing because students are specializing in one sport at an earlier age, meaning their feet don't get a break from heavy pounding on the turf.

"Anecdotally, people are saying they feel like they're seeing it more," says Dr. Daniel Farber, an orthopedic surgeon specializing in foot and ankle injuries at University of Maryland Medical Center. "In my practice, I see it as more cyclical. You tend to get it a bit in the spring and the fall as athletes are ramping up their activity."

Farber says sports with "push-off" motions, including basketball and baseball, also make players susceptible. The factor most at play among Farber's pediatric patients is a tight heel chord, which puts stress on the entire area between the plantar fascia (the connective tissue that runs from the heel to the toes) and the Achilles tendon.

"Something's got to give," says Farber. "The growth plate is really what takes the brunt of it."

And when not given enough time off, the heel will also become intensely inflamed. A key symptom is refusal to bear weight on the affected foot.

George Kalas III learned about Sever's the hard way. Though his son, Gus, had been favoring his right foot for months and eventually began limping, the 9-year-old wouldn't acknowledge the pain. During a lacrosse game last fall, the condition finally became intolerable.

"He could hardly put any weight on it," says Kalas, of Davidsonville. "I had to carry him off of the field."

Diagnosing and treating Sever's

Expecting the worst, Gus' parents took him to the emergency room where X-rays indicated that nothing was wrong. Their next stop was the orthopedist.

Kalas said his son's doctor, like Spirt, pinpointed the condition with little more than a description of the pain. To diagnose most cases of Sever's, Spirt conducts a squeeze test on the heel. If pressure from both sides over the growth plate creates pain, she said, "that supports the diagnosis."

She also orders an X-ray to rule out other conditions, such as a bone cyst, tendonitis or fracture. That can be especially helpful in cases with swelling, or if children are often complaining of intense pain at night or even when they've gone days without intense activity.

At 9 years old, Sophia Ruschaupt's parents feared she had an overuse injury from playing soccer and lacrosse. Switching her to a goalie position and eliminating most of her running didn't ease the Crofton girl's pain.

"We iced and elevated it for about a week and she still had peculiar pain in her heel. Nothing seemed to help," said her mother, Tricia Ruschaupt. "She was fine walking, but when she would run in cleats on the field, she would have heel pain pretty quickly. She would sit out for a bit and go back in the game, but the pain would come back."

That kind of specific, focal pain is a classic Sever's symptom, said Farber. Visible swelling and redness, however, are unusual. And if the pain is similar in more than one part of the body or a patient reports a more widespread ache, a doctor may need to order tests to rule out a chronic condition such as Lyme's disease.

In true Sever's cases, patients will outgrow the condition once their heel bone fuses and development is complete.

Managing the pain

Farber says parents should take their children's complaints of pain seriously.

"If they're not willing to bear weight on it, that's an indication that they need to be seen," he said. For most families, a visit to a pediatrician or family doctor should be all that's required for a diagnosis.

Even children who come in with severe pain often want to keep playing.

Farber has yet to put any of his Sever's patients in a cast, opting in worst-case scenarios (5 to 10 percent of all cases) to use a removable boot that provides cushion during walking and other light activity. He might issue a "don't play" warning for a two-week period, but often lets the child make his or her own decision about returning to play.

"It's going to annoy you," he warns. "It's up to you just how much pain you want to tolerate."

Ruschaupt's parents limited her running from March, when her injury became noticeable, through most of the summer. And they swapped her flip-flops for supportive athletic shoes. She returned to sports that fall. Now 12, she is pain-free.

Initially, Gus Kalas' doctor prescribed a soft cast boot, and he had to take a three-month break from sports. But by January, the condition seemed to have resolved itself. His parents allowed him to attend the first basketball practice of the season. But after just 20 minutes and a few lay-ups, the pain returned. He was benched again.

"It was hard for him to sit there, but he understood," said George Kalas.

To head off future reoccurrences, Gus began seeing a physical therapist who recommended a series of stretches using an exercise band. He also had a custom heel insert glued into his cleats and picked up over-the-counter versions for his non-playing shoes. This summer, the now 10-year-old returned to football and made it through a month of practice before a new round of pain began. He's added lace-up ankle braces and an anti-inflammatory medication to his regimen.

"It's basically pain management," his father said.

Sever's and other growing pains

Sever's syndrome is one of a handful of conditions caused when still-growing children place intense physical demands on their bodies.

Sever's syndrome
Also called calcaneal apophysitis, Sever's results from inflammation of the growth plate in the heel. It usually occurs during an adolescent growth spurt if the heel bone grows faster than the leg muscles and tendons. This can overstretch the muscles and tendons, making the heel less flexible and putting pressure on the growth plate. Over time, repeated stress (force or pressure) causes swelling, tenderness and pain.

Osgood-Schaltter disease
Osgood-Schlatter disease can cause a painful lump below the kneecap in children and adolescents. It affects as many as one in five adolescent athletes, usually those involved in sports that involve running, jumping and swift changes of direction. During those types of activities, a child's thigh muscles pull on the tendon that connects the kneecap to the shinbone. Repeated stress can cause the tendon to pull away from the shinbone, resulting in the pain and swelling. The condition usually resolves on its own, once the child's bones stop growing.

Sinding-Larsen-Johansson (SLJ) syndrome
This syndrome is a painful knee condition that most commonly affects teens during periods of rapid growth. The kneecap, or patella, is connected to the shinbone, or tibia, by the patellar tendon. Repetitive stress on the patellar tendon can cause a growth plate in the leg to become irritated and inflamed. SLJ happens largely between the ages of 10 and 15 and is more common in teens that play sports that require running or jumping.

Sources: Mayo Clinic, Nemours.

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