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Severs disease: is it impact related or from the achilles pull?

Discussion in 'Pediatrics' started by Craig Payne, Apr 1, 2012.

  1. Craig Payne

    Craig Payne Moderator

    Articles:
    7

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    Been pondering this ...

    Is severs disease due to the impact on the growth plate with the ground or is severs disease due to the pull from the achilles tendon on the growth plate?
     
  2. Peter

    Peter Well-Known Member

    Dare I also add that plantar fascia and plantar intrinsic musculature traction on the plantar aspect of the growth plate may also cause severs?
     
  3. Bruce Williams

    Bruce Williams Well-Known Member

    I think Peter is correct. I think it is more distal proximal traction related from the Achilles insertion and the plantar fascia. AJ equines plays a huge role as well.
    Cherre,
    Bruce
     
  4. Rob Kidd

    Rob Kidd Well-Known Member

    When one looks carefullly at the morphology of the apophyseal plate - and more to the point, its metaphyseal edges, one notes the decidedly "crenelated" nature of the union. It is carefully designed such that is resists extensile stress. Then, take a foot and abuse it - pronate (or probably supinate it), and then add in other factors such as sport etc, and the plate is no longer aligned in a manner such to resist tensile tresses. That is, there is a tendency to "slide" along the crenelations. Thus what we are looking at is micro-movement along the plate. Severs is like much of bone morphology - it is a tyrany of three dimensions. Rob
     
  5. W J Liggins

    W J Liggins Well-Known Member

    Just dealt with a case of a 14 year old rugby player. The initial complaint followed 'studding'. The first MRI report discounted trauma per se but was sent on by the Radiologist to a colleague for a second opinion. Co-incidentally, his 13 year old son had just suffered Severs, so he had an interest. His opinion was that the condition was caused by traction apophysitis of the TA insertion into the calcaneus.

    I suppose that this could be a fruitful study?

    All the best

    Bill
     
  6. Yes.

    And apart from the initial aetiology, there is no doubt in my mind that the loading of the heel can aggravate an existing severs.

    I've seen an awful lot of severs lately. It seems to come in two flavours, proximal part of the growth plate and distil part of the growth plate. Might be relevant...
     
  7. Bruce Williams

    Bruce Williams Well-Known Member

    Robb,
    So you are saying it is more of a torque than just simple traction, or a combination of both?

    I'm curious about your pronate / supinate statement as well. Do you think this is an issue seen more in rectus feet than in Planus feet? I know it is not that simple, but I'm looking for clarification of your statement
    Thanks.
    Bruce
     
  8. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    Thanks.

    I take Peter's additional point about the load from the intrinsic structures and Bob's point about alignment changing the tensile forces.

    My motivation for asking was that my standard initial approach to Severs has always been a cushioned heel raise (ie 3-4mm hard EVA & 6mm poron) .. the rationale being it could be the plantar load from the ground and/or the pull from the achilles.

    I follow a number of barefoot running blogs and forums, especially looking at advice on all the injuries they keep getting (mainly because of the paradox of barefoot running supposed to decrease/prevent injuries, yet all over the barefoot sites are runners wanting advice on their injury! ... don't figure).

    On a number of those forums recently have been barefoot runners asking for advice for their kids severs disease .... almost always the advice given is to get them barefoot and on to the forefoot. Its obvious that those giving the advice have never treated anyone with Severs disease before, yet still somehow feel qualified to give that advice. I am just curious where they are getting there information from that Severs is due to impact forces (hence the advice to go barefoot/forefoot strike), when the advice that are giving will probably increase the load on the growth plate from the increases achilles pull ??
     
  9. Stanley

    Stanley Well-Known Member

    I think we have to look at both the plantar fascia and the Achilles tendon.
    I find this most often related to sports which have greater forces on the foot, and especially in sports with jumping such as basketball.
    Landing on the forefoot requires deceleration via the gastrocnemius and soleus. This increases tension in both the Achilles and the plantar fascia.
    A simple force diagram will show the combined vector will cause compression of the apophysis and perpendicular to that we will see increased tension forces within the apophysis.
    Knowing that calcification is related to pressure, we do see increased density of the apophysis with transverse lines of decreased calcification.
    That is not to say that shoes pronation will not cause increased tension in the plantar fascia and result in apopysitis by itself or an equinus will not cause it by itself either. Usually though the combination of equinus and pronation should be treated.
    Just my thoughts.
    Regards,
    Stanley
     
  10. musmed

    musmed Active Member

    Dear Stanley
    Hi, I agree with you in what you say
    but consider this:
    In Basketball when one has jumped and the toes forst hit the ground and there after, the Flexor digitorum brevis is firing +++

    Once the toes have dug into the shoes (toe of shoe on ground) and cannot move any more, the FDB must be pulling the calcaneus towards the toes and thus the intrinsics can be associated with Severs.

    Here the Flexor digitorum longus is firing to allow knee flexion control. For those who doubt look at the origin versus the place where the tendon passes under the malleolus. It is designed to control knee flexion.

    In summary anything can and will contribute to the problem.

    Regards
    Paul Conneely
    sunny day here!! (for a change)
    www.musmed.com.au
     
  11. Tess Bowen

    Tess Bowen Member

    Hi fellow decipeds,
    I know the question why is important ,you all sound as if you know why,it's a tug of war in two directions ,does lifting the heel work? mostly, does correcting excessive pronation and lifting the heel work ? usually if it doesn't then look further.
    How about putting some of this excessive energy into prevention of this condition.
    We know the age group at risk of developing severs so lets get out there and talk to schools/teams/coaches or run an information session through your local pharmacy.
    Why not ask if a kid has severs will they also develop plantar fasciitis down the track?
    its time for some longitudinal studies.
    May the foot be with you
    Tess
     
  12. Stanley

    Stanley Well-Known Member

    Hi Paul,

    I agree with what you are saying. I should have said that anything attaching to the calcaneus that supports the arch, such as the plantar fascia or the intrinsic foot muscles. By the way, speaking about the FDB, I find that there is a stretch injury to this muscle with a posterior calcaneus subluxation.

    Regards,
    Stanley
     
  13. RobinP

    RobinP Well-Known Member

    It is my experience that it is tensile load that is the primary factor(although I have no doubt that compression force can further irritate an existing condition)

    There seems to be a large number of kids for whom, just running(mainly heel strikers) is little problem but sports involving rapid periods of sprinting intermittently seem to have a much more damaging effect, and mainly after the event. These sprinting periods will generally involve going up on to the toes(increaseing the tensile force on the achilles and the aforementioned plantar structures)

    The mainstay of my treatment is much as with achilles tendinopathy where I am attempting to reduce the load on the achilles by increasing the lever arm to the sub talar joint axis.

    I do, however think that there is development of bony oedema from excessive tensile load which itself becomes a pathology which is why vertical compression of the calc upon weight bearing becomes problematic
     
  14. Dananberg

    Dananberg Active Member

    I think of Seaver's as being caught between a rock and hard place. The hard place is in the forefoot, with the rock being the pull of the Achilles. Children with Functional hallux limitus in particular are at risk. During running, heel lift is compromised due to the lack of forefoot pivot. Relieving the functional limitus makes a hugh difference.

    And on the clinical treatment, I have children return in 2-3 weeks after treatment is initiated with some type of foam foot orthotic. Invariably, the heel seat is too large when they return, as the swelling has decreased substantially. Orthotic is remolded at that time....and recurrence is minimalized.

    I have also found that PPT or poron heel lifts are really contraindicated in the management of Seaver's. They prolong heel contact too much when measured by F-scan. Firmer heel lifts, if really necessary, work much better.

    Howard
     
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