My Not So Scientific Study on Calcaneal Apophysitis (Sever’s Disease)

I have previously written on all my clinical work, research and teaching experiences with calcaneal apophysitis and just how much I realised I did not know and just how much I learnt when my own child got it. As my daughters have just come out of the age bracket where the condition is common, I used that opportunity over the last few years to chat to as many of their friends and their friend’s parents that I could about their experiences with ‘Severs Disease’ whenever I could (an unrepresentative purposively selected sample with recall bias and no ethics approval, but, hey no worries).

Based on my own recall bias, here is what I found:

  • most of the kids either had it or had a friend that had it
  • almost all of them knew of the special type of growing heel pain that occurs in kids
  • of those that got it, only a bit over half of them actually went to a health professional for treatment or advice
  • a wide variety of treatments were used and advice given
  • some of that advise or treatment, in my opinion, was bad and would have made no difference to the natural history of the condition
  • they all got better at an age before the growth plate would have merged with the rest of the calcaneus
  • a bit under two-thirds of them attributed the getting better to taking it easy (eg during school holidays) and not due to any specific treatment given
  • for many it lasted a while, but the symptoms were always there and manageable, but they got better eventually by doing nothing much
  • of those that got foot orthoses, NONE of them thought they actually made any difference (except one)!

Over recent years, I have started to question if there is actually anything we can do for Calcaneal apophysitis (Sever’s disease). I talked about a particularly painful case here with a massive improvement that all I did was say to them on Thursday, that I will see you Monday. Now I know you are not supposed to give much weight to anecdotes, especially if they fit in with your agenda or world view, but if you combine that anecdote with the experiences I had with my daughters, the unscientific study above and what was being published in peer-reviewed journals, then it is time for some self-reflection on one’s beliefs about the condition.

When we get to this stage, we should be relying on high-quality evidence from proper controlled and unbiased studies. There are not many. This one told us that heel raises do a bit better than foot orthoses, but neither really had a big impact (and that is sorta consistent with my unscientific study above). This study showed that doing nothing and just ‘wait and see’ works pretty well (and that is sorta consistent with my unscientific study above).

The use of foot orthoses to treat this is particularly problematic. The study linked in the previous paragraph showed they did not do too well. My cohort thought they were not particularly useful, yet you still see on a lot of podiatry websites claim that “overpronation” is a factor in calcaneal apophysitis (Sever’s disease) and therefore foot orthoses are needed. We know from the evidence that the claims about “overpronation” and this condition are false which removes the rationale as to why foot orthoses would be used.

Does this mean that we should just leave Calcaneal apophysitis (Sever’s disease) alone and not treat it? Of course not. I do now believe that this condition has its own good natural history and it gets better pretty much on its own regardless of any intervention. Yes, I know they grow out of it when the growth plate merges with the rest of the calcaneus, but I am talking about before that stage. Our role is simply one of education about the nature of the condition, managing expectations and managing loads. Terminology and words matter. Combine that with some ice for pain relief if it gets bad and maybe a cushioned heel raise and we good to go.

Any advocacy for any other treatments or interventions for this are going to have to be accompanied by actual evidence that they are better than a placebo or doing nothing due to the nature of the natural history of this condition. In clinical practice, did it get better because the intervention is better than a placebo or doing nothing or did it get better because it was going to anyway (ie natural history). That is why we need the actual evidence rather than unsubstantiated claims.

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For more, please check all the threads on this on Podiatry Arena and our PodChatLive with Alicia James.

Why Podiatrists Should be Concerned About Concussion in Sport

Concussions have always had a particular interest for me. The politics around concussion in sport and the alleged cover-ups and the significant public health consequences have long been a fascinating issue to follow. Will Smith’s 2015 movie, Concussion and the 2013 book, League of Denial highlighted just how political and controversial it has become. Who remembers or knows what the Lonergan Shuffle is?

Why should Podiatrists be concerned about concussions?

  1. Concussion in sport is a major public health issue, with significant long term societal and personal health and mental health effects. All health professionals should be concerned about and be proactive in all public health issues and educating the community about the issues and advocating for those issues. Smoking and obesity are other public health issues.
  2. There is a significantly increased risk for lower limb injury following a concussion and that risk can last for at least a year or so. There is a very large number of studies that have shown that. You can follow this thread which lists all those studies: Concussion and the lower limb and as a public health issue
  3. We are parents, we are members of the community; our kids are involved in community sport. We could be the first responder to a head injury in the community, especially at our kid’s sport.

On the third point above, I had a daughter who spent a few years playing full-contact rugby in a boys’ team. By default, I became the de facto ‘team doctor’. I freaked out every time one of the boys (or girl) went down with a potential head injury – mainly because I knew the consequences of a concussion. I always acted quickly and made sure play was halted until I took an appropriate action for a sideline HIA (Head Injury Assessment) and ruled out other trauma and then made the call to escalate or continue play, following appropriate guidelines. Luckily, they were a tough bunch and I never had to deal with one that was a concussion. Yes, I know my lane and I stay in it; but I am also a member of the community and in the context of the lack of other appropriate or more qualified cover, I was the first responder. We are required by Podiatry Board of Australia to be re-certified regularly in first aid. There is a reason for that.

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Postscript:
No sooner than I write the above, this study appears showing that those who have a time loss lower limb injury are more likely to go on and get a concussion.