Hello again. Congratulations to Megan for the fabulous first issue, I was completely amazed at how good the final product looked. I know I said in the last issue that I would cover shoulder injuries in this issue, but I received quite a few e-mails asking me to give some information on Severs disease. SEVER’S DISEASE
Sever’s disease, or calcaneal apophysitis as it is also known, is a common painful condition experienced by growing children.  The site of the pain is the calcaneal epiphysis (indicated by the white arrow on the X-Ray.) This is the growth plate of the heel. This is also the area where the Achilles tendon attaches.
 Pain is most commonly felt at the back of the heel. Occasionally there may be pain that “wraps” around the heel, ending on the bottom of the foot, near the beginning of the arch of the foot. This is due to the anatomy of the area. The Achilles tendon does not end at the calcaneus (the heel bone), but continues around and completes its insertion on the bottom of the bone where the long arch of the foot begins.
Pain may result in an inability to weight bear on the heel, and effectively the child starts to walk on his/her toes. Pain is usually aggravated through running and jumping.
Who is most affected?
This condition is most common in children between 10 and 14 years of age. It is very similar to Osgood-Schlatters disease in the knee. As with Osgood-Schlatters (see last months issue), Severs is caused by increased shearing forces on the growth plate. This causes mild swelling in the area and pain. As stated earlier, sports participation will worsen symptoms, but they often subside when activities are stopped. What can be done?
Due to rapid growth during the ages of 10 – 14, muscle flexibility needs to be assessed. Tight calf muscles (both the gastrocnemius and soleus) can exacerbate symptoms by adding to the shearing forces on the calcaneal epiphysis.  Children who tend to pronate experience these symptoms more often. Walking on the inside of the foot, as shown in the picture, can increase the shearing forces on the physeal plate, therefore increasing pain.
 Orthotics may be used to correct this problem. TREATMENT
The treatment for this condition is very simple. - Ice the affected area daily, even on the days when no pain is present. Ice should be applied for 20 minutes at least once a day. Remember using real ice (the cubes from the fridge) is preferable to the reusable icepacks. Reusable icepacks can be caustic to the skin. Ice massage is also a very effective method for icing the heel.
- Stretch the calf muscles. Remember the calf is made up of two muscles (one that attaches above the knee, gastrocnemius, and one that attaches below the knee, soleus). Two separate stretches need to be performed, one for each of the muscles.
 The image on the left stretches the upper calf. The image on the right stretches the lower calf.  Hold each stretch or 10 – 15 seconds and repeat 3 – 5 times. This should be repeated 5 – 10 times daily. 
The calf muscle can also be stretched by standing on a step and dropping the heel down as shown in the photo below.
- Arch stretching can also be effective in treating heel pain associated with Severs.
 Stretch the arch by placing the big toe on a wall, then sliding the foot to the floor.
 The arch can also be stretched by pulling the toes up and flexing the foot at the same time.
- Heel or calf raises should be performed to keep normal muscle strength in the calf muscles due to the decrease in the activity. Begin by performing 10 to 30 two leg calf raises, progressing in number as pain allows. If two leg calf raises become too easy, progress to one leg calf raises.
- Heel lifts can be inserted into shoes. The lift will help relieve some of the stress on the physeal plate.
 By raising the heel, the Achilles tendon will be lengthened, reducing the stress. Keep in mind, that stretching becomes more important when heel raises are used, as this will counteract any physical shortening that may occur in the tendon.
- Participation in sport should be according to levels of pain. If it hurts, rest and ice, and return to play when it is better.
 - Taping the arch or Achilles tendon may reduce pain and stress during participation therefore increasing performance.
Severs disease is often self-limiting; it will go away once the child completes the growth cycle. It is very rare that the child has to be removed from sporting activities, as most children with Severs will be able to continue participation with modifications that allow them to be pain free.Well that’s all from me for this month. If you have any questions on Severs or any other condition, please drop me a mail (adelegel@telkomsa.net). Keep on tumbling.
Adele | 
