What is the recommended treatment for a child diagnosed with Sever's disease?

Treatment of Sever's Disease in Children

The recommended treatment for Sever's disease in children should focus on conservative management including rest, physical therapy, stretching exercises, heel cups or orthotics, and pain management with ice and non-steroidal anti-inflammatory drugs.

Understanding Sever's Disease

Sever's disease (calcaneal apophysitis) is the most common cause of heel pain in children between the ages of 8 and 15 years. It is an overuse injury affecting the calcaneal growth plate, particularly common in physically active children who participate in high-impact sports such as soccer, track, gymnastics, tennis, and ballet 1, 2.

Diagnosis

Diagnosis is primarily clinical and includes:

• Positive "squeeze test" (pain when compressing the sides of the heel)
• Heel pain that worsens with activity
• Tight heel cords/Achilles tendon
• Pain with weight-bearing activities

While radiographic imaging may show increased sclerosis and fragmentation of the calcaneal apophysis, these findings are not necessary for diagnosis 2.

Treatment Algorithm

First-Line Management:

1. Rest and Activity Modification

   • Reduce or temporarily stop high-impact activities
   • Avoid barefoot walking
   • Consider short-term (1-2 weeks) activity restriction for severe cases

2. Ice Application

   • Apply ice to the affected heel for 15-20 minutes, 2-3 times daily
   • Particularly effective after physical activity

3. Stretching Exercises

   • Achilles tendon and calf stretching exercises 3-5 times daily
   • Hold stretches for 20-30 seconds, repeat 3-5 times per session

4. Supportive Footwear

   • Heel cups or heel lifts to reduce pressure on the calcaneal apophysis
   • Properly fitted athletic shoes with good arch support

Second-Line Management:

1. Pain Management

   • NSAIDs (e.g., ibuprofen) for pain and inflammation
   • Acetaminophen as an alternative if NSAIDs are contraindicated

2. Physical Therapy

   • Supervised stretching and strengthening exercises
   • Kinesiotherapy techniques
   • Possible use of Kinesio taping 3

3. Custom Orthotics

   • For cases not responding to over-the-counter heel cups
   • Particularly helpful for children with flat feet or high arches

For Severe or Persistent Cases:

1. Immobilization

   • Short-term use of walking boot or cast for severe cases
   • Usually limited to 1-2 weeks to prevent muscle atrophy

2. Gradual Return to Activity

   • Structured program to gradually reintroduce sports activities
   • Monitor symptoms and adjust activity levels accordingly

Expected Outcomes

Most cases of Sever's disease resolve within 2 weeks to 2 months with conservative treatment 4. The condition is self-limiting and typically resolves completely once the growth plate closes, usually by age 15 in boys and slightly earlier in girls.

Important Considerations

• Monitor for Complications: While rare, be vigilant for atypical presentations that might indicate complications such as osteomyelitis 5
• Education: Educate parents, coaches, and children about the condition, its self-limiting nature, and prevention strategies
• Prevention: Emphasize proper warm-up, stretching, appropriate footwear, and avoiding excessive training

Follow-up Recommendations

• Review after 2-4 weeks of conservative management
• Consider further investigation (MRI) for atypical cases or those not responding to treatment within 2 months
• Reassess biomechanics and footwear if symptoms recur

Sever's disease has no known long-term effects when properly managed 2, and the prognosis is excellent with appropriate conservative treatment.