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May 2013

Heel pain in youth - calcaneal apophysitis or Sever's disease

Severs Disease or calcaneal apophysitis
Definitive treatment for heel pain in teens is available at the office of San Antonio Podiatrist, Dr. Ed Davis

Heel pain is less common in children than adults and the causes are usually different.  It is unusual for plantar fasciitis to occur in youth.

The most common cause of heel pain in the approximately 9 to 14 year old age group is calcaneal apophysitis or Sever's disease.

The heel bone or calcaneus has a growth plate, that is, an open area of growing tissue that creates bone growth located at the posterior (back) area where the Achilles tendon attaches.  A growth plate is termed an "epiphysis" and a growth plate to which a tendon attaches is known as an "apophysis."   Inflammation at the apophysis of the heel bone is called "calcaneal apophysitis."

An x-ray of the heel bone in a child shows two areas of bone, the main part of the heel bone and a portion in the back with "space" in between the two bones.  That space gets smaller as the two bones grow toward each other.  Eventually, the space between the two bones disappears and the two bones become one.  That occurs between the ages of 13 to 15 although there is some variability.

The area between the "merging" heel bones or calcaneal apophysis appears most sensitive to overuse injury within 18 months to fusion, in my experience.

Most patients we see with calcaneal apophysitis present with certain factors in common:

1)  They are active in school sports; often soccer, basketball or football.

2)  A tight heel cord or Achilles tendon is frequently present.

3) They often display subtalar joint overpronation, that is, the foot/heel/arch tends to roll in excessively when walking and standing.

The popularity of school soccer has led to an increase in cases of calcaneal apophysitis in my practice.  Soccer shoes provide little protection for the heel and little support.

Here are some potential treatments to try before seeing a pediatric podiatrist:

1) Stretching of the Achilles tendon.  Should be done gently, especially if pain is present.

2) Use running shoes in lieu of soccer and basketball shoes when possible, that is, when not playing the game or in practice.

3) Consider a good OTC insert such as Powersteps or Superfeet.

4) Rest, icing and use good judgement.   Playing through pain can lead to further injury.


Seek professional treatment if self care is not effective.  The key issue is to identify the causes of the heel pain and target treatment to alleviate the causes.  If there  is excessive Achilles tightness or contracture then a course of manual therapy can be effective.  Significant overpronation is treated with a prescription orthotic.  We general use an orthotic design which has a deep heel cup.  The heel cup is the portion of the orthotic that surrounds the heel.  The orthotic may have a rearfoot post which is a wedge that stabilizes the heel, neutralizing excessive motion and stress on the growth plate.


 For more information on pediatric foot problems, visit:  Childrens Foot Doctor San Antonio

ESWT or extracorporeal shockwave therapy for the treatment of heel pain


ESWT is a treatment modality derived from renal lithotripsy in which high energy shock waves are used to break up kidney stones. The best way to understand the nature of a shock wave is to consider what happens when a tire blows out and the windows rattle afterwards. A acoustic wave or pressure wave is generated. The pressure waves that are used in lithotripsy or ESWT involve a very rapid increase in pressure followed by a rapid decrease in pressure.

Studies performed on kidney tissue via biopsies after renal lithotripsy noted a surprising finding, that the kidney tissue in the path of the shockwave became much healthier than surrounding tissue. That led to research as to how shockwaves applied with the right intensity and frequency can cause damaged tissue to repair itself. This technology led to a new industry, ESWT, which involves the use of controlled shockwave energy applied to damaged tissue to effect a repair.

Initially, studies led to somewhat variable results as the type of human tissue which ESWT has a beneficial effect on was not known. The key issue is to differentiate tissue that is inflamed from tissue which is degenerated. The term “fasciitis” means inflammation of the fascia and “tendinitis,” inflammation of a tendon. Our bodies appear to handle acute inflammation fairly well but have difficulty with chronic inflammation. Arteries which are chronically inflamed form plaque and clog; tendons which are chronically inflamed become thickened, filled with thick inflexible scar tissue which tends to crowd out the good tissue and reduce the blood supply to the tendon. That is true for fascia too. Fascia is connective tissue that surround muscle, giving it support. The blood supply (nutrition) to fascia generally comes from adjacent muscle tissue. When fascia becomes too thick or scarred, there is reduced circulation to it and it becomes diseased. We call that process, “fasciosis” if it involves the fascia or “tendinosis” if it involves tendon.

Dr. Harvey Lemont, a professor at the Temple University College of Podiatric Medicine, the school I graduated from, did a fascinating study which he published in 2003. He examined tissue samples taken from 50 patients undergoing surgery on the plantar fascia. Why were those patients being treated surgically? Because they had what was known to that point as “intractable plantar fasciitis,” in other words, heel pain caused by plantar fasciitis which did not respond to conventional conservative treatments. He found that the plantar fascia in those patients showed no signs of inflammation but degeneration instead, ie. Plantar fasciosis.  With the advent of ESWT, surgical treatment of plantar fasciosis is rarely required.

ESWT is a treatment for plantar fasciosis, not plantar fasciitis.

ESWT is a treatment for Achilles tendinosis., not tendinitis.

How does one know if plantar fasciosis or Achilles tendinosis is the cause of heel pain? The best way to know for sure is to perform imaging, either MRI or diagnostic ultrasound (sonography). We generally perform diagnostic ultrasound as it is relatively quick and inexpensive.

There are different technologies to provide ESWT which I will cover in a later post.   We use the Swiss Dolorclast made by EMS, the Storz/Curamedix  Orthopulse  and the Storz/Curamedix Intellect FS-W focused ESWT units in our office.  

Dr. Ed Davis – “heel pain doctor” in San Antonio    heel pain doctor


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