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Calcaneal Apohysitis or Stress fracture

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Dec 1, 2010.

  1. David Smith

    David Smith Well-Known Member

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    Dear all

    I have a young patient 12yr old male who has heel pain especially after sports and at the end of the day after school but with shoes off it is less painful. The pain can only be elicited by lateral compression of the calc, i.e. squeezing, but not by pressure applied to one side or the other. There is no visible swelling. He did have ankle equinus (I mobilised ankles to increase D/flex RoM significantly) and a very pronated foot posture.

    My Dx was calc stress fracture (diff Dx calc apophysitis)and advised immobilising with Short Aircast boot for 3 weeks. The onset was about 3 months ago. He has had attended an NHS clinic previously and had rigid orthoses prescribed as treatment but no diagnosis given except 'growing pains'.

    I ordered x ray and bone scan, X ray report states negative for fracture or any abnormality, bone scan has not been done but MRI has been done but no report available yet.

    I viewed the X rays today and this is my main query here. I have not viewed many juvenille x rays and would like to ask if you think this is a normal apophysis for a 12yr old boy. NB I do not yet have copies of the x-ray and this x ray pic below is not the patient's but a stock photo that is very similar. Are there any specific features that would identify apophysitis or Servers disease from an x ray.


    Regards Dave Smith
    Last edited: Dec 1, 2010
  2. Graham

    Graham RIP

    Looks like a bad case of Severe's disease. Heel raises and an appropriate orthoses would likely help along with physiotherapy. In less sever cases just the heel raise is often enough. (Both sides of course unless symptoms present on a short limb).
  3. No exactly sure what your after Dave but maybe this helps ?

    Attached Files:

  4. David Smith

    David Smith Well-Known Member


    Thanks for the paper, what I'm asking is is this a normal calcaneal x ray. I suspected a stress fracture. The radiology report said no fracture (but we know x rays are not so sensitive to stress fracture in the calc, which is why I asked for a bone scan also) and no other abnormalities seen. Which would indicate that the calc x ray was normal. I'm inexperienced in assessing the juvenille foot x ray and I'm asking do you think it is normal i.e. is the x ray, shown in my post, normal.? Or would you say it is an indication of apohysitis / servers disease, bearing in mind that this is a 12 year old boy and the epiphysis will not be fully ossified yet.

    Also bearing in mind that the only way to elicit pain is by squeezing the heel and there is no swelling or significant achilles or retro calcaneal bursa pain and the ankle was equinis with tight ach ten and PF, would you suspect a calc stress fracture?

  5. I would maybe keep it in the back of my mind - but squeeze test the only way to get a pain response would say to me Severs and treat accordingly - But I´m no Pediatric Pod either. Maybe your mate Isaacs or Sally S or Cylie who work with the little critters everyday might be able to help out.

    But I would think Severs a stress reaction or Stress fracture would in my option have greater and more symptoms
  6. drsarbes

    drsarbes Well-Known Member

    The X-Ray appears like a normal apophysis and given the Hx and Age of your patient I would Dx as Apophysitis. In my experience bone scans are not helpful since open epiphyses and apophyses light up as a normal finding. Variations in the density of the apophysis on plain films is also normal.

    I would treat as an apophysitis and go from there. I feel an MRI is not warranted.

  7. Craig Payne

    Craig Payne Moderator


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