Sever's Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations

Possible association between Sever's disease and attention deficit hyperactivity disorder. a prospective observational study

BACKGROUND

Sever's disease is among the most common causes of foot pain in childhood.The etiology of Sever's disease is still under debate.The objective of this prospective study is to investigate the relationship between Sever's disease and attention deficit hyperactivity disorder(ADHD).

METHODS

The study was prospectively conducted for 1 year between 2023-2024.Of 238 children admitted to our clinic with foot pain, 88 children diagnosed with Sever's disease were included in the study.A control group including 90 individuals was employed.Patients diagnosed with Sever's disease in the orthopedics outpatient clinic and healthy control group were evaluated by a pediatric psychiatrist in terms of ADHD based on the DSM-4 diagnostic criteria.

RESULTS

Fifty-seven patients were male, and 31 were female.While 45 male patients were diagnosed with ADHD, 12 of them did not have ADHD.While 17 female patients were diagnosed with ADHD, 14 did not have ADHD. ADHD was detected in 12 (13.3%) of 90 patients in the control group, comprising 9 boys and 3 girls. The prevalence of ADHD in the Sever's disease cohort was 62 (70.5%) out of 88, significantly higher than the control group's 12 (13.3%) out of 90 patients (p < 0.01). The high number of the patients diagnosed with ADHD among the Sever's patients who were not engaged in sports was found to be statistically significant(p < 0.01).The diagnosis of ADHD was found to be statistically more significant in boys with Sever's disease compared to girls(p < 0.018).

CONCLUSION

Children with Sever's disease can be the candidates for attention deficit hyperactivity disorder.It is thought that evaluating children, especially male children, diagnosed with calcaneal apophysitis within the framework of attention deficit hyperactivity disorder will be valuable.

Physical characteristics inducing Sever's disease in junior gymnasts

Objective

This prospective cohort study aimed to determine characteristics contributing to the development of Sever's disease in junior gymnasts.

Methods

This study included 74 limbs from 37 junior gymnasts. The Baseline demographic data, flexibility measurements, foot alignments, trunk function tests, and functional balancing tests were used for evaluation. The incidence of Sever's disease among this cohort was assessed for six months after the first evaluations. We categorized those diagnosed by medical specialists as having Sever's disease into a Sever's disease group, while those with no foot pain or other diagnosed pathologies were in a no-symptom group.

Results

The Junior gymnasts with Sever's disease had a lower arch height ratio and lower anterior star excursion balance test values.

Conclusions

Sever's disease in junior gymnasts may be potentially prevented through using a medial longitudinal arch support and/or undertaking dynamic postural balance training.

Exploring the Link Between Calcaneal Apophysis Maturation and Heel Pain in Youth Baseball Players

Background

Calcaneal apophysitis is the most common cause of heel pain in children and adolescents. However, the relationship between skeletal maturity and heel pain in the specific youth cohort is unclear.

Purpose

To clarify the relationship between the maturity stages of the calcaneal apophysis and heel pain in youth baseball players.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A total of 336 youth male baseball players participated in this study. Ultrasound scanning of the calcaneal apophysis was performed along the longitudinal line connecting the middle of the Achilles tendon, the middle of the calcaneus, and the second toe, between the proximal calcaneal edge and the medial calcaneal tubercle. The authors classified the maturity of the calcaneal apophysis into 5 stages, from nonpresence of the apophysis (stage 1) to complete fusion (stage 5). The diagnosis of heel pain was based on subjective report of feeling pain on the squeeze test. The relationship between the maturity stages and physical characteristics was investigated using 1-way analysis of variance or the Kruskal-Wallis test, and the relationship between the maturity stages and heel pain was investigated using the chi-square test.

Results

Of the 336 players, 49 had heel pain, for a prevalence of 14.6%. Eighteen (5.4%) players had unilateral heel pain, and 31 (9.2%) players had bilateral heel pain. There were no significant differences in the maturity stages of the calcaneal apophysis between the players with no heel pain and those with heel pain. However, no players had heel pain during stage 5, when the calcaneus had completed its maturation.

Conclusion

The prevalence of heel pain was 14.6% in Japanese youth male baseball players. There was no relationship between the maturity stages of the calcaneal apophysis and heel pain. Heel pain that could be associated with calcaneal apophysitis did not occur during stage 5, when maturation of the calcaneal apophysis was complete.

Solving the Puzzle: A Compelling Case Study of Calcaneal Apophysitis With Achilles Tendon Calcification in a 14-Year-Old Patient

Calcaneal apophysitis, known as Sever's disease, manifests as heel pain and is prevalent among children and adolescents, particularly during growth spurts and periods of heightened physical activity. Although Sever's disease is well-documented, its co-occurrence with other foot pathologies in pediatric patients is relatively uncommon. We present here a unique case of a 14-year-old female patient who presented with significant heel pain and discomfort associated with flat feet, impacting her daily activities and physical performance. Clinical examination revealed tenderness at the heel consistent with Sever's disease, along with symptoms suggestive of posterior tibial tendinopathy and radiographic evidence of Achilles tendon calcification. The primary diagnoses included Sever's disease, posterior tibial tendinopathy, and calcification of the Achilles tendon. Management involved a thorough assessment comprising physical examination and imaging studies to confirm the diagnoses. Pharmacological and non-pharmacological interventions such as activity modification, stretching exercises, and orthotic devices were implemented to alleviate symptoms and improve foot mechanics. Over the course of treatment, the patient showed gradual improvement in pain levels and functional abilities, indicating a positive response to therapy. Long-term follow-up aimed at preventing recurrence and optimizing foot health was recommended to ensure sustained recovery and overall well-being. In this case study, we aim to elucidate the clinical presentation, diagnostic challenges, and management approach employed in addressing these concurrent foot conditions. By exploring this case, we hope to contribute valuable insights to the understanding and management of pediatric foot pathologies, particularly in cases involving multiple co-existing conditions.

The Pediatric Ankle: Normal Variations and Maturation-Dependent Pathology

The pediatric ankle can present a broad range of normal variation and pathology unique to certain stages of development. Understanding the expected age ranges of ossification and fusion about the ankle is essential to provide accurate diagnoses regarding skeletal integrity. This conclusion has been well characterized radiographically and is supported by cadaveric research.The range of appearances on magnetic resonance imaging has also been well described. Knowledge about the structure of the periosteum and perichondrium aids in image interpretation as well as explaining typical injury patterns. The expected appearance of the physis and regional bone marrow signal is also of utmost importance.Ultrasonography is a valuable tool in pediatric musculoskeletal imaging but is limited when there is concern for intra-articular pathology. Computed tomography tends to be reserved for preoperative evaluation. We describe normal variation and maturation-dependent pathology of the pediatric ankle with an emphasis on imaging considerations.

Paediatric Calcaneal Osteochondroma: A Case Report and a Literature Review

BACKGROUND

Heel pain in children is a common condition. The aetiology can be ascribed to fractures, osteochondrosis, tendinitis, calcaneal-navicular or talo-calcaneal coalition, osteomyelitis, rheumatic diseases, anatomic variants, malignant tumours (osteosarcoma, Ewing's sarcoma), and benign lesions (bone cyst, aneurismal bone cyst, osteoid osteoma, or exostosis). In particular, this manuscript focuses on a case of calcaneal exostosis in the paediatric age, aiming to highlight its rarity. Osteochondromas are benign tumours of the surface of the bone and the overlying cartilage. They grow until skeletal maturity and can cause stiffness, pain, cosmetic alterations, tendinitis, and neuro-vascular compression. The calcaneus is an extremely rare site for these tumours. Only two case reports of paediatric exostosis of the calcaneus bone are available.

METHODS

We describe a case of a girl of 16 years of age, affected by multiple cartilaginous exostosis, who presented with a painful mass on the inferior margin of the foot in the calcaneal region, which was diagnosed as an exostosis. The neoformation was excised, and the girl underwent clinical follow-up.

RESULTS

The patient was promptly discharged in good condition, and on the 25th postoperative day, she was completely pain-free and allowed weight bearing.

CONCLUSIONS

In the case of heel pain resistant to conservative treatment, the presence of an osteochondroma should be considered after excluding more common causes. If symptomatic, calcaneal osteochondromas could require surgical excision.

Foot pain in children and adolescents: a problem-based approach in musculoskeletal ultrasonography

Various etiologies and risk factors contribute to foot pain in children and adolescents, including conditions such as Kohler's disease, Sever's disease, Iselin's disease, rigid flat foot, accessory navicular, Freiberg's disease, sesamoiditis, os trigonum syndrome, and more. High-frequency musculoskeletal ultrasonography can show both the bone surface and the surrounding soft tissue clearly from various angles in real-time, thereby providing a higher level of detail that is helpful for identifying the etiology of foot pain and monitoring disease progression compared with other imaging modalities. This review provides an overview of the epidemiology, pathophysiology, clinical manifestations and characteristic ultrasonographic findings of select foot pain conditions in children and adolescents.

Conservative Treatment of Sever's Disease: A Systematic Review

Background: Sever's disease, or calcaneal apophysitis, stands as the most prevalent cause of heel pain in children, often linked to sports like soccer, Australian football, and basketball. While various therapies are documented in the scientific literature, the standard choice is conservative treatment. Thus, the objective of this research was to assess the effectiveness of diverse conservative methods and techniques in alleviating Sever's disease symptoms. Methods: Systematic searches were conducted in October 2023 in PubMed, Web of Science, Scopus, SportDiscus, and PEDro, using terms like Osteochondritis, Osteochondrosis, Apophysitis, Sever's disease, Calcaneus, Adolescent, Child, and Childhood. The PEDro scale gauged methodological quality, and the Cochrane Risk of Bias tool evaluated the risk of bias. Results: Eight randomized controlled studies were included, featuring commonly used treatments such as insoles, therapeutic exercises, Kinesio taping, and foot orthoses. The methodological quality was generally good, with an average PEDro score of 6.75 points. Regarding bias, four articles had low risk, three had high risk, and one had some concern. Conclusions: Conservative treatment emerges as an effective option for alleviating symptoms associated with Sever's disease.

Characteristics of Pressure on the Apophysis in the Course of Paediatric Heel Pain-Preliminary Report

Increased pressure on the heel apophysis is often implicated as a cause of paediatric heel pain. However, there are few reports on the causes of the increased pressure and its origin. Therefore, the aim of this study was to analyse the distribution of pressure on the feet in children with heel pain. The study included 33 paediatric patients with non-traumatic heel pain, i.e., 24 boys (73%) and 9 girls (27%), aged on average 11.2 years (±3 years). Pedobarographic diagnostics proved a decrease in the pressure on the heels in relation to the ground and the transfer of the projection of the centre of gravity to the forefoot. While standing, the average contribution of the pressure on the heel was 0.52, SD = 0.14 in children with normal and reduced weight. In overweight children, the average pressure on the heel was higher (0.60, SD = 0.08), but the small number of children with this characteristic (n = 4) did not allow conclusions to be drawn in this area. Heel underload was also demonstrated during gait. However, the assessment of this aspect requires additional observational analyses in the field of propulsion and gait phases. The reduced pressure on the heel promotes apophysis traction, causing intracanal compression. Studies have shown that the causes of apophysis traction may be postural defects (in particular, forward inclination of body posture) and overpronation of the foot, or defects in the metatarsal area.