What Exactly Is Severs Disease?
Overview
Sever?s disease occurs in children when the growing part of the heel is injured. This growing part is called the growth plate. The foot is one of the first body parts to grow to full size. This usually occurs in early puberty. During this time, bones often grow faster than muscles and tendons. As a result, muscles and tendons become ?tight.? The heel area is less flexible. During weight-bearing activity (activity performed while standing), the tight heel tendons may put too much pressure at the back of the heel (where the Achilles tendon attaches). This may injure the heel.
Causes
The calcaneal apophysis develops as an independent center of ossification (possibly multiple). It appears in boys aged 9-10 years and fuses by age 17 years, it appears in girls at slightly younger ages. During the rapid growth surrounding puberty, the apophyseal line appears to be weakened further because of increased fragile calcified cartilage. Microfractures are believed to occur because of shear stress leading to the normal progression of fracture healing. This theory explains the clinical picture and the radiographic appearance of resorption, fragmentation, and increased sclerosis leading to eventual union. The radiographs showing fragmentation of the apophysis are not diagnostic, because multiple centers of ossification may exist in the normal apophysis, as noted. However, the degree of involvement in children displaying the clinical symptoms of Sever disease appears to be more pronounced. In a study of 56 male students from a soccer academy, of whom 28 had Sever disease and 28 were healthy control subjects, findings suggested that higher heel plantar pressures under dynamic and static conditions were associated with Sever disease, though it was not established whether the elevated pressures predisposed to or resulted from the disease. Gastrocnemius ankle equinus also appeared to be a predisposing factor.
Symptoms
The typical clinical presentation is an active child (aged 9-10 years) who complains of pain at the posterior heel that is made worse by sports, especially those involving running or jumping. The onset is usually gradual. Often, the pain has been relieved somewhat with rest and consequently has been patiently monitored by the patient, parents, coaches, trainers, and family physicians, in the expectation that it will resolve. When the pain continues to interfere with sports performance and then with daily activities, further consultation is sought. It should be kept in mind that failure to instruct patients and parents that continual pain, significant swelling or redness, and fever are not signs of Sever disease and therefore require further evaluation could result in failure to diagnose a condition with much more serious long-term consequences.
Diagnosis
Your podiatrist will take a comprehensive medical history and perform a physical examination including a gait analysis. The assessment will include foot posture assessment, joint flexibility (or range of motion), biomechanical assessment of the foot, ankle and leg, foot and leg muscle strength testing, footwear assessment, school shoes and athletic footwear, gait analysis, to look for abnormalities in the way the feet move during gait, Pain provocation tests eg calcaneal squeeze test. X-rays are not usually required to diagnose Sever?s disease.
Non Surgical Treatment
Treatment aim is to lessen the load on the insertion of the Achilles tendon, along with pain relief if necessary. This can be achieved by modifying/reducing activity levels. Shoe inserts or heel raises. Calf stretches. Avoiding barefoot walking. Strapping or taping the foot to reduce movement. Orthotic therapy if due to biomechanical causes. Other treatment includes icing of the painful area to reduce swelling, pain medication if necessary and immobilisation of the affected limb in severe or long standing cases.
Prevention
Sever?s disease may be prevented by maintaining good flexibility while your child is growing. The stretching exercises mentioned here can lower your child?s risk for injuries during the growth spurt. Good-quality shoes with firm support and a shock-absorbent sole will help. Your child should avoid excessive running on hard surfaces. If your child has already recovered from Sever?s disease, stretching and putting ice on the heel after activity will help keep your child from getting this condition again.
Sever?s disease occurs in children when the growing part of the heel is injured. This growing part is called the growth plate. The foot is one of the first body parts to grow to full size. This usually occurs in early puberty. During this time, bones often grow faster than muscles and tendons. As a result, muscles and tendons become ?tight.? The heel area is less flexible. During weight-bearing activity (activity performed while standing), the tight heel tendons may put too much pressure at the back of the heel (where the Achilles tendon attaches). This may injure the heel.
Causes
The calcaneal apophysis develops as an independent center of ossification (possibly multiple). It appears in boys aged 9-10 years and fuses by age 17 years, it appears in girls at slightly younger ages. During the rapid growth surrounding puberty, the apophyseal line appears to be weakened further because of increased fragile calcified cartilage. Microfractures are believed to occur because of shear stress leading to the normal progression of fracture healing. This theory explains the clinical picture and the radiographic appearance of resorption, fragmentation, and increased sclerosis leading to eventual union. The radiographs showing fragmentation of the apophysis are not diagnostic, because multiple centers of ossification may exist in the normal apophysis, as noted. However, the degree of involvement in children displaying the clinical symptoms of Sever disease appears to be more pronounced. In a study of 56 male students from a soccer academy, of whom 28 had Sever disease and 28 were healthy control subjects, findings suggested that higher heel plantar pressures under dynamic and static conditions were associated with Sever disease, though it was not established whether the elevated pressures predisposed to or resulted from the disease. Gastrocnemius ankle equinus also appeared to be a predisposing factor.
Symptoms
The typical clinical presentation is an active child (aged 9-10 years) who complains of pain at the posterior heel that is made worse by sports, especially those involving running or jumping. The onset is usually gradual. Often, the pain has been relieved somewhat with rest and consequently has been patiently monitored by the patient, parents, coaches, trainers, and family physicians, in the expectation that it will resolve. When the pain continues to interfere with sports performance and then with daily activities, further consultation is sought. It should be kept in mind that failure to instruct patients and parents that continual pain, significant swelling or redness, and fever are not signs of Sever disease and therefore require further evaluation could result in failure to diagnose a condition with much more serious long-term consequences.
Diagnosis
Your podiatrist will take a comprehensive medical history and perform a physical examination including a gait analysis. The assessment will include foot posture assessment, joint flexibility (or range of motion), biomechanical assessment of the foot, ankle and leg, foot and leg muscle strength testing, footwear assessment, school shoes and athletic footwear, gait analysis, to look for abnormalities in the way the feet move during gait, Pain provocation tests eg calcaneal squeeze test. X-rays are not usually required to diagnose Sever?s disease.
Non Surgical Treatment
Treatment aim is to lessen the load on the insertion of the Achilles tendon, along with pain relief if necessary. This can be achieved by modifying/reducing activity levels. Shoe inserts or heel raises. Calf stretches. Avoiding barefoot walking. Strapping or taping the foot to reduce movement. Orthotic therapy if due to biomechanical causes. Other treatment includes icing of the painful area to reduce swelling, pain medication if necessary and immobilisation of the affected limb in severe or long standing cases.
Prevention
Sever?s disease may be prevented by maintaining good flexibility while your child is growing. The stretching exercises mentioned here can lower your child?s risk for injuries during the growth spurt. Good-quality shoes with firm support and a shock-absorbent sole will help. Your child should avoid excessive running on hard surfaces. If your child has already recovered from Sever?s disease, stretching and putting ice on the heel after activity will help keep your child from getting this condition again.
Acquired Flat Foot Causing Toe Pain
Overview Tendons do a lot of work. In fact, a great deal of what happens when you walk can be related to tendons tugging and pulling in appropriate ways in their proper places. With this in mind, it?s hardly surprising that on occasion, (probably because we too often forget to send them ?Thank you? cards), tendons may decide that they?ve had it. They may buck their responsibilities, shirk their work, and in all other ways cease to function properly. And that may mean bad news for you. Take the posterior tibial tendon: it runs from the bottom of the calf, goes right under that bump on the inside of the ankle (the medial malleolus) and ends up attaching itself to a bone on the inside of the middle of your foot (the navicular bone). It?s the main tendon that keeps the arch of your foot in place, and it helps a bunch in walking, too. Over time, though, we tend to put a lot of stress on this faithful tendon, especially if we?ve put on extra weight, or do a lot of activities that stress it out, walking, running, hiking, or climbing stairs. Sometimes athletes (who do a lot of that walking and running stuff) may put so much stress on the tendon that it tears suddenly. But for many of us, damage may take place gradually (i.e. the tendon stretches out) until the tendon tells us that it flat out quits. (It sometimes doesn?t even give two weeks notice.) In short, you may develop posterior tibial tendon dysfunction (PTTD). 
Causes As discussed above, many different problems can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to support the arch of your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the posterior tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In addition, people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis, can cause a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also causes the foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch. An injury to the tendons or ligaments in the foot can cause the joints to fall out of alignment. The ligaments support the bones and prevent them from moving. If the ligaments are torn, the foot will become flat and painful. This more commonly occurs in the middle of the foot (Lisfranc injury), but can also occur in the back of the foot. Injuries to tendons of the foot can occur either in one instance (traumatically) or with repeated use over time (overuse injury). Regardless of the cause, if tendon function is altered, the forces that are transmitted across joints in the foot are changed and this can lead to increased stress on joint cartilage and ligaments. In addition to tendon and ligament injuries, fractures and dislocations of the bones in the midfoot can also lead to a flatfoot deformity. People with diabetes or with nerve problems that limits normal feeling in the feet, can have collapse of the arch or of the entire foot. This type of arch collapse is typically more severe than that seen in patients with normal feeling in their feet. In addition to the ligaments not holding the bones in place, the bones themselves can sometimes fracture and disintegrate without the patient feeling any pain. This may result in a severely deformed foot that is very challenging to correct with surgery. Special shoes or braces are the best method for dealing with this problem. Symptoms Patients often experience pain and/or deformity at the ankle or hindfoot. When the posterior tibial tendon does not work properly, a number of changes can occur to the foot and ankle. In the earlier stages, symptoms often include pain and tenderness along the posterior tibial tendon behind the inside of the ankle. As the tendon progressively fails, deformity of the foot and ankle may occur. This deformity can include progressive flattening of the arch, shifting of the heel so that it no longer is aligned underneath the rest of the leg, rotation and deformity of the forefoot, tightening of the heel cord, development of arthritis, and deformity of the ankle joint. At certain stages of this disorder, pain may shift from the inside to the outside aspect of the ankle as the heel shifts outward and structures are pinched laterally. Diagnosis The diagnosis of posterior tibial tendon dysfunction and AAFD is usually made from a combination of symptoms, physical exam and x-ray imaging. The location of pain, shape of the foot, flexibility of the hindfoot joints and gait all may help your physician make the diagnosis and also assess how advanced the problem is. Non surgical Treatment Stage one deformities usually respond to conservative or non-surgical therapy such as anti-inflammatory medication, casting, functional orthotics or a foot ankle orthosis called a Richie Brace. If these modalities are unsuccessful surgery is warranted. 
Surgical Treatment If initial conservative therapy of posterior tibial tendon insufficiency fails, surgical treatment is considered. Operative treatment of stage 1 disease involves release of the tendon sheath, tenosynovectomy, debridement of the tendon with excision of flap tears, and repair of longitudinal tears. A short-leg walking cast is worn for 3 weeks postoperatively. Teasdall and Johnson reported complete relief of pain in 74% of 14 patients undergoing this treatment regimen for stage 1 disease. Surgical debridement of tenosynovitis in early stages is believed to possibly prevent progression of disease to later stages of dysfunction.
