Should we x-ray for Sever's Disease?

NewsBot · Aug 14, 2009

Members do not see these Ads. Sign Up.
Do we really need radiographic assessment for the diagnosis of non-specific heel pain (calcaneal apophysitis) in children?
Kose O.
Skeletal Radiol. 2009 Aug 12. [Epub ahead of print]

OBJECTIVE: Non-specific heel pain (calcaneal apophysitis) is a common disorder, particularly in physically active growing children. Foot radiographs are usually obtained as part of the clinical evaluation in routine orthopaedic practice. However, there is still controversy about the specific findings on radiographs, and it is unclear what information is present on radiographs that may alter the diagnosis and management. The purpose of this study was to review a consecutive series of patients with the diagnosis of calcaneal apophysitis to assess the yield of routine radiographs of the foot.

MATERIAL AND METHODS: A prospective study was performed on 61 consecutive patients with a diagnosis of calcaneal apophysitis in a single-surgeon practice. Standard anteroposterior and lateral weight-bearing foot radiographs were obtained for each patient. Seventy-one sets of foot radiographs were reviewed to determine whether radiographs had an impact on diagnosis and management. Patients with antecedent trauma, penetrating injury, foot deformity, achilles tendonitis, bursitis and infections were excluded from the study.

RESULTS: Seventy foot radiographs were considered to be normal. The radiographs changed the diagnosis in only one patient, in whom a simple bone cyst of the calcaneous was seen.

CONCLUSION: Calcaneal apophysitis is a self-limiting disease, and patients can be treated conservatively. Neither the sclerosis nor the fragmentation of the apophysis could be used to establish the diagnosis of calcaneal apophysitis. Therefore, obtaining radiographs as an initial step in their evaluation does not seem to be justified.
Click to expand...

Admin2 · Aug 14, 2009

Related threads:
Other threads tagged with: calcaneal apophysitis and severs disease

Teash13 · Aug 14, 2009

I have not yet xrayed anyone for a Severs diagnosis. I don't think it is neccesary if you get positive squeeze tests and heel raise tests. Why would you subject kids to radiation that is not really needed or beneficial to the diagnosis.

Ella Hurrell · Aug 14, 2009

Teash13 said: ↑

I have not yet xrayed anyone for a Severs diagnosis. I don't think it is neccesary if you get positive squeeze tests and heel raise tests. Why would you subject kids to radiation that is not really needed or beneficial to the diagnosis.
Click to expand...

I agree - Severs is a clinical diagnosis for me, based on history and clinical tests. I have never requested x-ray unless Severs is not the likely cause. I had one patient who appeared to have Severs but the history just didn't fit. MRI showed Bone Marrow Oedema and he was diagnosed with Juvenille Arthritis.

Kevin Kirby · Aug 14, 2009

On the initial presentation of Sever's disease, I will not perform routine radiographs. However, if the patient does not respond appropriately to normal conservative treatment (i.e. heel lifts, reduced running, icing, gradual Achilles tendon stretching, and no barefoot walking) then I believe it is important to rule out other causes of heel pain with radiographs of the feet.

NewsBot · May 1, 2010

Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever's disease)?
Kose O, Celiktas M, Yigit S, Kisin B.
J Pediatr Orthop B. 2010 Apr 29. [Epub ahead of print]

The purpose of this study was to investigate whether the identification of Sever's disease is reliable with radiographs alone. Eighty foot radiographs (50 boys with calcaneal apophysitis and 30 healthy boys) were included in this study. Two consultant orthopaedic surgeons were instructed to make a diagnosis without clinical information on the patients. Radiologic assessments were performed in random order by each observer on two separate occasions, at least 3 weeks later. kappa-statistics were used to establish a relative level of agreement between observers for the two readings and between separate readings by the same observer. Observer A made 22 true (27.5%) diagnoses, whereas observer B made 56 true (70%) diagnoses at the first assessment. Interobserver agreement was rated as slight (kappa-value, 0.190). Observer A made 40 true (50%) diagnoses, whereas observer B made 52 true (65%) diagnoses at the second assessment. Interobserver agreement was rated as slight (kappa-value, 0.039). Intraobserver reproducibility was rated as fair for both observers (kappa-value, 0.369 for observer A and 0.253 for observer B). The results of this study showed that the radiologic identification of calcaneal apophysitis without the absence of clinical information was not reliable. Radiologic findings that were attributed to Sever's disease showed a wide variation between independent observers and between separate readings by the same observer. The diagnosis of calcaneal apophysitis is a clinical decision and radiographic assessment seems to be unnecessary.
Click to expand...

NewsBot · Jun 10, 2011

Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (sever disease)?
Rachel JN, Williams JB, Sawyer JR, Warner WC, Kelly DM.
J Pediatr Orthop. 2011 Jul-Aug;31(5):548-50.

BACKGROUND:
Calcaneal apophysitis (Sever disease) is most often diagnosed clinically, and radiographic evaluation is believed to be unnecessary by many physicians. To evaluate the need for radiographic evaluation in children with a clinical diagnosis of calcaneal apophysitis, we determined the frequency of abnormal radiographic findings in a group of patients with this clinical diagnosis.

METHODS:
Clinical records and radiographs of all children between the age of 4 and 17 years who presented with a chief complaint of heel pain were retrospectively reviewed. Patients with an insidious onset of heel pain were included; those with acute trauma and a diagnosis of Achilles tendinitis were excluded. Radiographs were reviewed by 3 orthopaedists (blinded to the clinical diagnosis) to determine if any radiographic abnormalities were present. Clinical records were reviewed in an attempt to determine what factors, if any, indicated a diagnosis other than calcaneal apophysitis.

RESULTS:
Review identified 98 patients (134 feet) with a mean age of 10.8 years who had a clinical diagnosis of calcaneal apophysitis. Positive radiographic findings (all on lateral radiographs) were identified in 5 patients (5 feet): 3 calcaneal unicameral bone cysts, 1 distal tibial nonossifying fibroma, and 2 calcaneal stress fractures (1 patient had both a calcaneal unicameral bone cysts and a stress fracture in the same foot). The rate of abnormal radiographic findings in the 96 patients was 5.1% (3.75% in the 133 feet).

CONCLUSIONS:
The abnormal radiographic findings seen in 5.1% of children usually led to more aggressive treatment including close radiographic follow-up or immobilization. No common findings in the history or examination indicated patients who were more likely to have positive radiographs. Despite concern about exposure to ionizing radiation and the cost of medical imaging, routine lateral radiographs appear to be justified for screening of pediatric patients with heel pain. If a diagnosis of calcaneal apophysitis is made without obtaining radiographs, a lesion requiring more aggressive treatment could be missed.
Click to expand...

NewsBot · Sep 27, 2013

Sever’s Injury
A Clinical Diagnosis
Stefan Perhamre, Dagmara Lazowska, Sofia Papageorgiou, Fredrik Lundin, Maria Klässbo and Rolf Norlin
J Am Podiatr Med Assoc 103(5): 361–368, 2013

Background: The diagnosis of Sever’s injury (apophysitis calcanei) has previously been partly based on radiographic findings in the calcaneal apophysis. Sclerosis and fragmentation have been supposed to represent signs of inflammation due to tractions from the Achilles tendon. The clinical findings, diagnostic criteria, and studied population are often poorly defined. We sought to define diagnostic criteria by analyzing clinical and radiographic characteristics in a population with Sever’s injury and to compare the findings with those of a control group of matched, symptom-free children.

Methods: We assessed 30 consecutive children with Sever’s injury with high levels of pain but high physical activity levels in sports activities and 15 pain-free matched controls.

Results: One-leg heel standing showed 100% sensitivity; the squeeze test, 97%; and the palpation test, 80%. All three tests showed 100% specificity. All of the patients and controls showed increased density of the apophysis. Half of the pain-free controls showed fragmentation versus almost 90% of children with heel pain.

Conclusions: The diagnosis of Sever’s injury is clinical, not radiologic. Radiologic findings of increased density and fragmentation are found also in pain-free controls with high levels of physical activity and may, therefore, represent normal growth and development. We suggest that the diagnosis of Sever’s injury should be based on patient history and the results of two specific clinical tests.
Click to expand...

NewsBot · Sep 16, 2014

MRI findings of a case with bilateral calcaneal apophysitis
Berat Acu, Taylan Kara, Safiye Topaloğlu Aşçı, Ayşegül Altunkaş.
J Contemp Med. 2014; 4(Supplement Case Reports): CR-29-CR-31

Introduction:
Calcaneal apophysitis (CA) is the most common cause of heel pain in patients before the ossification of calcaneal epiphysis. We report magnetic resonance imaging (MRI) findings of a case with bilateral CA.

A 9 year-old male patient with bilateral foot pain was referred to our department for MRI. On bilateral foot MRI, bilateral decreased signal intensity on T1-weighted images, increased signal intensity on fat suppressed T2-weighted images that represents edema, subchondral erosions located tuber calcanei, insertion of Achilles tendon were detected. The diagnosis was bilateral calcaneal apophysitis.

Discussion:
Sever's disease or CA is a common but frequently undiagnosed source of heel pain in young athletes. It is an inflammation of the calcaneal apophysis believed to be caused by repetitive microtrauma from the traction of the Achilles tendon on the unossified apophysis. It frequently occurs before or during the peak growth spurt and often shortly after a child begins a new sport or season. It is usually seen among 8-15 age group. Patients typically have no features such as swelling, skin changes, erythema, or other local abnormalities. It is usually a self limited disease, most of them usually resolves in two weeks to two months after the initiation of conservative treatment, and in more severe cases, nonsteroidal anti-inflammatory drugs.
Osseous erosion at metaphysis of the neighboring to calcaneal apophysis is the finding of CA on MRI. Similar signal difference may be seen at the secondary apophysial ossification centers.
Click to expand...

Craig Payne · Sep 18, 2014

Just stumbled on this 2013 case report in BMJ cases that claims to see x-ray and MRI changes:
http://casereports.bmj.com/content/2013/bcr-2013-009758.full

NewsBot · Jan 11, 2016

Normal skeletal development and imaging pitfalls of the calcaneal apophysis: MRI features.
Rossi I et al
Skeletal Radiol. 2016 Jan 9

OBJECTIVE:
Heel pain in children and secondary MR imaging (MRI) of the hindfoot have been increasing in incidence. Our purpose is to illustrate the, previously unreported, MRI stages in development of the posterior calcaneal apophysis, with attention to imaging pitfalls. This should aid in distinguishing normal growth from true disease.
MATERIAL AND METHODS:
Consecutive ankle MRIs in children <18 years, from 2008-2014, were subdivided into 0≤5, 5≤10, 10≤15 and 15≤18 age groups and retrospectively reviewed for development of the calcaneal apophysis.
RESULTS:
204 ankle MRI studies in 188 children were identified. 40 studies were excluded with final cohort of 164 studies in 154 patients (82 boys, 72 girls). The calcaneal apophysis was cartilaginous until age 5. Foci of decreased as well as increased signal were embedded in cartilage, prior to ossification. Early, secondary ossification centers appeared in plantar third of the apophysis in 100 % of children by age 7. Increased T2 signal in the ossifications was seen in 30 % of children. Apohyseal fusion began at 12 and was complete in 78 % of 14≤15 year olds and in 88 % of 15≤18 year olds. Curvilinear low signal in the ossification centers, paralleling, but distinguished from growth plate, and not be confused with fracture line, was common.
CONCLUSION:
Development of the posterior calcaneus follows a unique sequence. Apophyseal fusion occurs earlier than reported in the literature. Familiarity with this maturation pattern, in particular the apophyseal increased T2 signal and the linear low signal paralleling the growth plate, will avoid misinterpreting it for pathology.
Click to expand...

NewsBot · Jan 24, 2016

Calcaneal Apophysitis (Sever’s Disease): MRI Findings
Dogan MS et al
J. Nepal Paediatr. Soc. (Full text)

Calcaneal apophysitis (Sever’s disease), is the most frequent
cause of the heel pain in growing children. The diagnosisis
generally made with a typical history and clinical examination.
Imaging modalities including radiography and magnetic
resonance imaging can help establish the diagnosis. In this case
we report imaging findings of an 11-year-old boy diagnosed as
Sever’s disease.
Click to expand...

NewsBot · Jun 3, 2020

Radiographic study of Sever's disease
Yan Gao Jia Liu Yifang Li Qing Liu Shuhua Xu
Experimental and Therapeutic Medicine 0.0 (1898): 0-0. : May 26, 2020

X-ray and MRI differences of calcaneal epiphysis between Sever's disease patients and normal children were compared and analyzed to raise awareness of Sever's disease. A total of 98 children with Sever's disease were enrolled in the study, including 72 males and 26 females. Among them, 6 patients underwent MRI. There were 120 patients in the control group, including 73 males and 47 females, aged 8 to 15 years. The calcaneus epiphysis density (compact and cancellous bone type), the difference of the radiolucent line and the signal changes of Sever's disease on MRI of the two groups were observed and analyzed. Among the patients with Sever's disease, the male incidence rate was 79.59%, the female incidence rate was 20.41%, the average age of onset was 11.35, the average age of onset for male was 11.49, and the average age of onset for female was 10.80. There were significant statistical differences between the two groups in terms of epiphysis density (compact and cancellous type) and translucent line (χ2=38.85, 137.51, P<0.05). Six cases of MRI showed partial or complete different degrees of bone marrow, ligament, soft tissue edema, and joint effusion. Sever's disease is mainly characterized by increased density of the calcaneus epiphysis and a radiolucent line of the epiphysis. It manifests as heel edema on MRI image.
Click to expand...

NewsBot · Feb 2, 2021

Calcaneal stress fracture diagnosed by MRI
Journal of Pediatric Surgery Case Reports
Volume 66, March 2021, 101795

Highlights
•Calcaneal stress fractures in children are rare but seem underdiagnosed.
•Radiographs are often negative in the early stages.
•Calcaneal stress fractures can be misclassified as Sever's injury when radiographs are negative.
•Calcaneal stress fracture can by diagnosed by MRI or bone scintigraphy in the early stages.
•Consider an MRI when a child presents with heel pain and no evidient trauma not to overlook calcaneal stress fractures.
Click to expand...

This case report demonstrates a paediatric calcaneal stress fracture not seen on traditional radiograph but diagnosed by MRI. A young athlete presented at age 15 with heel pain and no trauma. Calcaneal stress fractures in children are rare and could be underdiagnosed since radiographs are often false negative especially in the early stages. Therefore, calcaneal stress fractures with a normal radiograph could be misclassified as Server's injury. The treatment strategy for a calcaneal stress fracture is more aggressive than for Server's injury and therefore distinction towards a stress fracture is important to choose the optimal treatment. Consequently, when a child presents with acute limp, refusal to walk and/or heel pain, with no evident trauma and negative radiographs further investigation is needed. We propose performing a bone scintigraphy or MRI to avoid overlooking stress fractures of the calcaneus and misclassify these fractures as Sever's injury.
Click to expand...

NewsBot · Jun 1, 2021

Sever’s Disease
M. Ouali Idrissi, S.Ouassil, B.Boutakioute, N. Cherif Idrissi El Ganouni
Sch J App Med Sci, 2021 May 9(5): 684-685.

Sever’s disease, also known as calcaneal apophysitis or calcaneoapophysitis, was first described by Haglund1 in 1907,
it has been described in various ways and attributed to a variety of causative factors. We report a case of a 15-year-old
adolescent who presented with bilateral mechanical talalgia and whose diagnosis was made by standard radiography.
Click to expand...

NewsBot The Admin that posts the news.

Admin2 Administrator Staff Member

Teash13 Member

Ella Hurrell Active Member

Kevin Kirby MVP

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

Craig Payne Moderator

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

NewsBot The Admin that posts the news.

Why the Term "First Ray Hypermobility" Should Become Extinct

Where Should the First Ray be When Casting for Orthoses?

Foot sole stretching and foam rolling and shoulder range of motion

Why Podiatrists Should Use Heel Lifts In Their Practice

Arch Supports should NOT be used in treating a Flexible Flatfoot

Do we all have feet half as strong as they should be ?

Should Adolescents Run Marathons?

Share This Page