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Sever's disease in a 4y/o???

Discussion in 'Pediatrics' started by ives, Dec 29, 2009.

  1. ives

    ives Member

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    i have a 4 1/2 y/o boy c/o pain in both ankles.
    pain present for 2 weeks, and is intermittant. pain worse in evenings and sometimes in mornings.
    pain is localized around posterior calcanei and over distal A/T, with mild pain on med/lat compression of calcanei. dorsiflexion at ankle elicits pain as well.

    Dx: Sever's disease? but never had a case at such a young age, and can't find any case history of same.

    pt is very active, and mostly barefoot.

    treatment to date: topical NSAID's, icing, and mild stretching. all with little efficacy.
    heel raises prove difficult as pt wont wear shoes, but will be starting school in aprox. 3 weeks.
    concidering night splints and taping.

    any suggestion please.
  2. When you said that the patient won't wear shoes, and the patient is 4.5 years old, then there is the problem..........unless the boy drove himself in to the appointmant.:rolleyes:

    When treating children, you are also treating the parents. Tell the parents that their child needs to wear shoes with heel lifts, needs to do calf stretching and needs to avoid going barefoot or he will continue to have pain. If they say "he won't wear shoes", then tell them the next line of treatment would be bilateral below knee fiberglass casts. If they don't like that then ask them "who is the boss in your home, your son or you?"

    The treatment of the child is simple....however, the treatment of the parent-child interaction is much more difficult.:drinks
  3. Admin2

    Admin2 Administrator Staff Member

  4. ives

    ives Member

    thanks, i'm fairly well equiped with treatment knowledge of Sever's disease, and am well aware of problem parents, and not much has changed in the last 30yrs.

    let me post a clearer question...

    Sever's in a 4 1/2 y/o??? does it exist?
    after hours of searching, i have only come across one case history involving a 2 y/o and that was a mis-diagnosis.

    am i missing something here, should i run other examinations?
  5. Sever's disease is possible in this age group, although quite uncommon, especially if they are running around barefoot all day, due to the compression trauma and tension trauma that will occur to the calcaneal apophysis.

    If you are suspicious of other disease processes, then what other diagnostic tests have you ordered for the child? Have you performed radiographs, bone scans or done any blood tests? Have you asked about new activities in the last few weeks? Have you had the parents bring in all the child's shoes so you can inspect them for possible irritation points? Have you told the child's parents to have him only be in shoes and has he responded to this treatment? It would be helpful if you gave us more information so we could help you more.
  6. I can see in your location that you are in South Africia.

    Also is the Child Africian. I was born in Zambia and my mother had a work friend who had an Africian boy 1 week after me. I am from a anglo saxon background and my mother and her friend would compair millstone of our development. I know that I walked very early for an anglo saxon background child but the Africian child had been running around for a few months by that time. It could be that children of Africian decent develop at a faster rate. So your 4 year old may infact be better compaired to a 6-7 year old in the studies that your looking at due to the fact that people of different origions may develop at different rates.

    I have no scientific proof of this but have been bored with the developmential story for years. Maybe something to consider.
  7. Adrian Misseri

    Adrian Misseri Active Member


    I agree with Kevin, further investigation is definately needed. I'd probably start with an ultrasound of the posterior calcanei and achillies tendons. Following that, I'd be looking at an MRI to see what state the cartlidge in the growth plates are in. Given the age of the child and the bilateral presentation, I'd be thinking some sort of atypical anatomical development?

    Cheers.. keep us posted!!
  8. Sally Smillie

    Sally Smillie Active Member

    apologies if I'm stating the obvious, but why must it be Severs? Achilles tendonitis is not unusual at all at this age, especially if he's not using shoes and TA is tight.

    STRETCH STRECTCH STRETCH! There is no reason why a child that age should not be subject to a full stretching regime. Might need to show a paretn assisted stretch and prepare them for a less than enthusiatic response from the child. Minimum hold of 30-60 seconds, 5 per leg per day, days a week. Advise them that full compliance is needed to see results. He needs about 25 degrees ankle dorsiflexion. There is always serial casting, but we advise parents that this is only a burst, and they may still need to continue with static stretching after casting is complete.

    He will more than likely be a bit weak too. If it is TA tendonitis, it is really important to strengthen gastrocs too. Single leg heel raises are best, but he mightbe a bit too young yet for that. Try walking on tip toes games.

    Good luck, let us know how you get on.
  9. I have never seen achilles tendinitis/tendinosus cause calcaneal pain or pain with side to side compression of the calcaneus. However, these clinical findings are commonly present in Sever's disease. In fact, in this age group, in my quarter century of treating children, I don't think I have ever seen an achilles tendinitis, unless it was traumatic in origin....it's all been Sever's disease.
  10. Sally Smillie

    Sally Smillie Active Member

    Kevin, you are quite right - I clearly missed the part where lateral compression was described. However, it was stated as 'mild'. The test itself does cause some dicsomfort, a postive test to this may yields a response of hitting the roof and yelp.
    Could it be that a 4 1/2 year old to have a 'mild' response to the test, may simply be a reaction to the discomfort?

    I am very interested in what you said about Severs this young, do you see many of them in under 5's? Certainly almost every child I see (predominantly boys) over 6 and under 13 is Severs, but much less below that age group. I'm keen to hear your thoughts

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