Bilateral sever´s disease–an uncommon finding

doi:10.15406/jpnc.2018.08.00320

Journal of

eISSN: 2373-4426

Pediatrics & Neonatal Care

Case Report Volume 8 Issue 2

Bilateral sever´s disease–an uncommon finding

Marcio Luis Duarte,

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Bruno Fernandes Barros Brehme de Abreu, Maura Harumi Ito, Maria Gabriela Varandas Costa, Jose Luiz Masson de Almeida Prado, Marcelo de Queiroz Pereira da Silva

Radiology, Webimagem, Sao Paulo, Brazil

Correspondence: Márcio Luís Duarte, Webimagem, Avenida Marquês de São Vicente 446, São Paulo, Brazil

Received: November 24, 2017 | Published: April 19, 2018

Citation: Duarte ML, Abreu BFBB, Ito MH, et al. Bilateral sever's disease–an uncommon finding. J Pediatr Neonatal Care. 2018;8(2):110-111. DOI: 10.15406/jpnc.2018.08.00320

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Abstract

Calcaneal apophysitis is a common cause of heel pain in children and is also known as Sever´s disease. Rarely causes important disability and is transient in most of the times, but it can interfere with walking and physical performance in sports, causing concern to the patient and parents. It is the most common cause of heel pain in the physically active growing children–8-25 years-old–and is considered a benign, self-limiting condition of childhood and adolescence. Boys constitute two-thirds of the patients and the sport that tends to dominate is soccer. The diagnosis of calcaneal apophysitis is usually made with a typical history and physical examination. Pain with activity, especially running and jumping, and a positive “squeeze test”: pain is produced by medial and lateral compression of the heel where the calcaneal apophysis attaches to the main body of the calcaneus. Children with Sever’s disease don´t have growth disturbances in the calcaneal apophysis or any vary in bone density compatible with a necrotic or a repair process. Children with Sever’s disorder respond variably, poorly, or not at all to anti-inflammatory drugs. Heel cup fixating the heel pad provided better pain relief in young boys with Sever’s injury compared with the traditional heel wedge.

Keywords: calcaneus/diagnostic imaging, calcaneus/pathology, child

Abbreviations

MRI: Magnetic resonance imaging

Introduction

Calcaneal apophysitis is a common cause of heel pain in children and is also known as Sever´s disease.^1,2 Rarely causes important disability and is transient in most of the times, but it can interfere with walking and physical performance in sports, causing concern to the patient and parents.¹ It is the most common cause of heel pain in the physically active growing children–8-25 years-old–and is considered a benign, self-limiting condition of childhood and adolescence.^2–4 Boys constitute two-thirds of the patients and the sport that tends to dominate is soccer.⁵ Sever´s disease is a chronic (repetitive) injury to the actively remodeling trabecular metaphysical bone that results in a variably sized stress injury with concomitant trabecular micro failure, hemorrhage, and edema, which is evident on MRI.⁴

Case presentation

8 years-old boy with pain in the heel of both feet for three months. The pain started when they started to play basketball. Deny traumas and surgeries. Indicates pain at local palpation and walking. MRI demonstrated irregularity of calcaneal apophysis with important edema, corresponding to Sever's disease, with discrete edema of surrounding subcutaneous tissue, in both feet (Figure 1) (Figure 2).

Figure 1 Sagittal MRI of the right foot in T2 SPIR sequence in A and T1 sequence in B demonstrating irregularity of calcaneal apophysis with important edema, corresponding to Sever's disease (blue arrow).

Figure 2 Sagittal MRI of the left foot in T2 SPIR sequence in A and T1 sequence in B demonstrating irregularity of calcaneal apophysis with important edema, corresponding to Sever's disease (blue arrow).

Discussion

The diagnosis of calcaneal apophysitis is usually made with a typical history and physical examination.² Pain with activity, especially running and jumping, and a positive “squeeze test”: pain is produced by medial and lateral compression of the heel where the calcaneal apophysis attaches to the main body of the calcaneus.^3,5Foot x-rays are performed as part of the clinical evaluation in routine orthopedic practice.² Increased density and fragmentation of the calcaneal apophysis are the two radiologic signs that are postulated to be noticeable differences between the radiographs of children with calcaneal apophysitis compared with their asymptomatic counterparts.² However, density of the calcaneal apophysis cannot be used as a pathognomic finding.²Fragmentation should not be misinterpreted as an abnormality; rather, it should be accepted as a normal variant.^2,5 Furthermore, x-ray can be normal in Sever´s disease.⁴ X-rays can be used to rule out other causes of heel pain in children such as a bone cyst, osteoid osteoma, stress fractures or tarsal coalition.^2,3,6 Lateral radiographs alone are sufficient to rule out other pathology and additional orthogonal views are unnecessary for screening purposes, thereby reducing radiation exposure and cost.³ MRI will show edematous changes within the calcaneal apophysis, possibly extending into the adjacent calcaneal tuberosity.⁶ Moreover, in equivocal cases, MRI can be helpful in rule out other diseases of heel pain.⁶ Children with Sever’s disease don´t have growth disturbances in the calcaneal apophysis or any vary in bone density compatible with a necrotic or a repair process.¹ Children with Sever’s disorder respond variably, poorly, or not at all to anti-inflammatory drugs.⁴ Heel cup fixating the heel pad provided better pain relief in young boys with Sever’s injury compared with the traditional heel wedge.⁵