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TWO Articles on Sever's Disease aka Retrocalcaneal Apophysitis.
[ARTICLE 1]
ACORN September 1998
By: Michael Zapf, DPM, MPH, FACFAS, FACFAOM
You’ve got to feel for Derrick. He wants to show the football coaches how well he
can run and he can barely walk. He was fine all summer working part time, going to the
beach and just hangin’ out. Now he is sitting in my office with feet that can barely
get him to class, let alone down the football field.
Derrick is complaining of painful heels. Specifically he is pointing to the back of his
heels just below the attachment site of the Achilles’ tendon. It is tender to touch
and it hurts when he places it on the floor. Touching it reveals that it is ever so
slightly warmer than a normal heel. I know from past experience that this is the location
of the so-called growth plate of the heel bone.
In reality it is not a growth plate but to call it by its proper name, the apophysis,
is using a little too much medical speak. The heel bone starts life as a block of
cartilage. Slowly the body turns the cartilage into bone. It does it from two sites, one
forward and a smaller one aft. The growth plate is actually a cartilage bridge between the
two areas of bone. The fore bone is attached to a ligament (the plantar fascia) pulling
one way and the aft bone is attached to the Achilles’ tendon pulling another. The
physical pounding of running and jumping combined with the pulling of these two tendons
can make the area of the growth plate very painful. The condition is known as Severs or
Sever’ Disease, or, for medical purists, calcaneal apophysitis. Older textbooks
referred to Sever’s as just a guy disease, but gender equality in sports leads to the
same gender equality in Sever’s.
Sever’s can last for 6 to 18 months. The good news for Derrick is that x-rays show
that his bridge will become bone in a couple of months at which time the pain will go
away. The bad news is that until that happy day of union, he may suffer bouts of extreme
pain. My job is to make that time as comfortable as possible for my patients.
First aid for Sever’s includes heel elevation, ice, stretching and rest. I
recommend that young athletes with Severs get and wear a ¼" heel lift in all of
their flat or athletic shoes. Shoes with elevated heels can be substituted for the heel
lifts. To be avoided are bare feet, sandals, slippers and wearing only socks, even around
home. I stress that a whole day of being good can be negated by 30 minutes of running
around barefooted in the evening.
Prior to any athletic activities, Sever’s patients need to do gentle stretching of
the Achilles tendons. This should be a slow gentle stretch and not an aggressive bouncing.
If the stretching is hurting it is not helping and should be stopped for the time being.
Ice can be applied to the feet in a variety of ways. The easiest and cheapest is to
rest the feet on a bag of frozen peas, corn or reusable blue-ice for 15 minutes. Place a
towel on the ice source or keep a sock on the feet so the feet do not rest directly on the
ice. Massaging the heels is a better but less convenient method.
Resting the heel is the hardest part. If Derrick can identify the activities that most
aggravate his heels, they should be avoided. Derrick’s coach likes his athletes to
run up and down the bleacher steps but this is particularly painful. I have given him a
note to take to his coaches and P. E. teachers that gives Derrick permission to sit out
the most painful of activities. (I am sure coaches and P. E. teachers hate notes that give
the young athletes discretion over which activities they will avoid. I am sure some think
that the heels only seem to hurt when there is running involved on days over 90° . Seriously, only the child knows when he or she is in pain.)
Orthotics are sometimes helpful. I apply an orthopedic strapping to the foot that
simulates an orthotic. If the tape helps, then so will an orthotic. Using
anti-inflammatory medication to allow athletic participation is controversial. I usually
avoid it but some local doctors do it routinely.
I hope that by the time you read this Derrick is feeling better and that he is
impressing his coaches and running away from his heel pain.
Dr. Michael Zapf is a board certified podiatrist with offices in Agoura and Thousand
Oaks. He has just written a 21-page monograph on bunions. For more information or a copy
of the bunion monograph, please call his office at (818) 707-3668.
[article 2]
ACORN August 1995
The Heel of Hell Week.
By: Michael Zapf, D.P.M., M.P.H., F.A.C.F.O.
Hell week in high school has become a Fall ritual. From volleyball to football
our high school athletes are living their worst fears. From running on the beach at 6:00
a.m. to diagramming plays after the sun goes down, these spirited and exhausted athletes
are getting ready for their upcoming seasons. The first week is designed by the coaches to
be a trial by fire -- and it certainly is that.
Even if there is controversy on how much conditioning hell weeks impart, it is exciting
for he athletes and creates a sense of were-are-all-in-this-together team spirit.
It is not likely to disappear any time soon. The down side to hell week are the injuries
this initial intense activity creates. While many of these athletes are in year-round
condition, others are not. For some this is their first time in competitive sports and
they are not prepared for the rigors of a full day of running, jumping and drilling.
Injuries from shin splints to blisters are not uncommon. One of the lease appreciated, but
one I have seen three times in two weeks, is Sever’s disease. This is an
unfortunately dramatic name for a temporary condition that can put quite a damper on a
young athletes ability to run and jump.
The heel bone starts life as a block of cartilage that, like all cartilage, is
invisible on an x-ray. Slowly, starting from the center, the cartilage block fills with
calcium in a process called ossification. By the age of one year enough of the heel
bone has calcium that it looks like an almond on an x-ray. By the time the child is
approaching double digits, the heel bone is almost full of calcium and an x-ray of the
heel bone makes it look almost adult size. At this point an interesting phenomenon occurs.
A second site of ossification occurs at the very back of the heel bone leaving a thin
island of cartilage between them. This island is thought to be a growth plate and is
called an apophysis. With enough stress on this growth plate, hell week, for
example, it can begin to hurt. I have seen it hurt so much that the young athlete cannot
walk without a limp.
The good news is that Sever’s is self-limiting meaning it will go
away by itself, When the cartilage island fills in with calcium it will no longer hurt.
This takes about a year which can be an eternity to a 10- year old. The bad news is that
during that year it can hurt so much that athletic activities may need to be curtailed.
This can be devastating to a high school freshman who feels the need to establish his or
her credentials at their new school.
Temporary measures can make the condition more tolerable. The Achilles tendon attaches
to the apophysis. When it is tight, especially in patients with high arches, the
Sever’s condition can get worse. Heel lifts worn equally in both shoes reduce the
pull of the Achilles’ tendon and provides some relief. Ice massage provides temporary
relief. This is easily done with by peeling off the top one quarter of Styrofoam
coffee cup full of frozen water. Using the insulated bottom the
exposed ice can be rubbed over the painful heels. I recommend that the massage be done
after every practice and game as well as once before bed time. Ice massage should be
avoided just before athletic endeavors because it tends to make he tendons and muscles
tight.
The final self-help treatment is to avoid those exercises and activities that aggravate
the pain. I provide my athlete patients with a note for their coaches that allows them to
avoid painful activities. I know the coaches and physical education teachers hate this
note. Coaches and P. E. teachers are not generally in favor of letting their charges decide
on their own when they want to run sprints or up the bleachers. But no one except the
young patient knows the amount of pain they are having and aggravating the Sever’s
will only prolong the pain and time away from the sport. I
Sometimes these treatments do not suffice and others are needed. In particularly
difficult cases I have had to place a cast on the foot to put it at rest. Oral anti
inflammatory medications in teenage athletes are controversial. I try to void using them
just to keep a young athlete playing sports. I will consider them when the pain is too
great for him or her to go to school comfortably.
Sever’s disease is a condition that is not a s bad as its name but it can sure put
the hell in hell week.
.
Dr. Michael Zapf is a board certified podiatrist with offices in Agoura and Thousand
Oaks. For more information you can call his office at (818) 707-3668.
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