Case Study - Sever's Disease or Plantar Fasciitis by Karl Lockett

Can we differentiate between Sever’s disease and plantar fasciitis?

A 12-year-old boy presents to the Sydney heel pain clinic complaining of pain through the sole of his right foot of approximately 6 months, and his mother has been informed that he has either Sever’s disease or plantar fasciitis. He complains of pain around the base of the back of the right heel and is an active young boy who plays approximately 6 periods of physical exercise each week. This patient reports heel pain during physical activity and in particular the following morning. He does not feel any pain in his left heel. The right heel is slightly redder and is also warmer than left. The pain has caused him to limp during sport and he hobbles out of bed the following morning. His mum, did some on line research and concluded he was showing the signs of plantar fasciitis, but also wasn’t sure if he had Severs disease. The symptoms of these 2 conditions being very similar. Her sister once had plantar fasciitis and hence she was concerned that there was a familial or genetic tendency with these conditions. To this end, she went to see the family doctor who advised that the young boy probably had Sever’s and that he was possibly too young to have plantar fasciitis. Sever’s is very common between the ages of 7 and 14 and is common in physically active children.

In desperation, the child’s mother went to an on-line store and purchased a plantar fasciitis sock, which the boy was to wear to bed each night. As is commonly the case, the patient was unable to wear the sock for more than 3 hours, and he would wake up around midnight with excruciating heel pain, removing the sock. On occasions where the sock was a little looser, the patient was able to sleep through, and he did then report that the heel pain was a little easier the next day. However, the pain during the day time persisted.

Physical Assessment – Plantar Fasciitis or Sever’s Disease?

The sports podiatrist was suspicious of Sever’s disease but knew it was important to rule out plantar fasciitis, and hence carried out a thorough physical assessment. Firm pressure was applied to all aspects of the calcaneus, including the epiphysis, posteriorly and the attachment of the plantar fascia. The patient felt heel pain in all areas and it was decided to refer for ultra sound scan.

The ultra sound report came back and confirmed inflammation of the plantar fascia at the calcaneal attachment, hence plantar fasciitis. However, due to the pain on the back of the heel, along the line of the growth plate, and considering the child’s age and level of activity, it could be concluded that he also had Sever’s disease.

Biomechanical Assessment

The sports podiatrist carried out a bio mechanical assessment in order to determine the cause of the plantar fasciitis and Sever’s disease. With the patient standing barefoot the podiatrist took foot posture index measurements, in neutral and relaxed calcaneal stance positions. Arch heights were noted in both positions.

Subtalar joint axis was measured
Calf range was assessed
Quadriceps and hamstrings were assessed
Midfoot range of motion was assessed
Hip joint rotation was assessed
Tibial torsion was measured

Findings

The sports podiatrist was able to detect some biomechanical anomalies. The range of motion in the calf muscles was significantly reduced bilaterally. This restricted range of motion through the ankle joint creates pulling on the back of the heel which causes plantar fasciitis and Sever’s disease both. The patient also demonstrated ligament laxity, which causes over pronation while walking and running. During gait, the podiatrist observed significant calcaneal eversion, hence severe over pronation in both feet. This was confirmed during supine assessment of the subtalar joint Axis which was medially deviated. In a neutral calcaneal stance position, the patient demonstrated good medial arch contour. However, in a relaxed calcaneal stance position the medial arch dropped significantly and measured close to 10 mm bilaterally. Over pronation, leads to fallen arches which leads to elongation of the foot on the hole. This in turn can cause stretching and straining of the plantar fascia as the foot lengthens. These biomechanical findings are possible causes of plantar fasciitis, but not necessarily Sever’s disease.

Plantar Fasciitis Treatment

One of the most important things with plantar fasciitis treatment, is patient education. Quite often patients are engaging in treatments which they think help, but which actually irritate the condition long term. The podiatrist at the Sydney Heel Pain clinic installed a mobile phone application entitled Sydney Heel Pain mobile app, onto the patient’s phone, which includes all the information required to successfully treat plantar fasciitis. The app also contains information on treatment of Sever’s disease, and includes instructions on calf stretching technique. In addition to the mobile phone application, the patient’s mother was informed that the treatment for these two conditions would be multifactorial. One of the most important things would be the calf stretching and the use of appropriate footwear. The patient was given specific footwear models to wear during sport and schooling. The podiatrist also carried out some deep tissue massage and some dry needling on the posterior aspect of the calf. Both feet were strapped with rigid sports tape, and 2 x 9 mm heel wedges were inserted inside the patient’s shoes in order to elevate the heel. This would take pressure off the growth plate in the calcaneus, which would reduce the symptoms of the Sever’s disease. The heel wedges were to be used as a short to medium term treatment, and the patient’s mother was informed that they would not be used for more than two to three months, and could be removed once symptoms had subsided. The patient was advised to refrain from running a sporting activity for the next 3 weeks. The patient was asked to return to the clinic on a weekly basis so that further massage, dry needling and sports tape application could be carried out.

After 3 weeks, the symptoms of the plantar fasciitis, and Sever’s disease had reduced significantly but as is to be expected there was still some residual pain. Due to the significant improvement, the sports podiatrist decided not to change the treatment plan but to continue with the same. After a total of 5 weeks of treatment, the symptoms of the plantar fasciitis had subsided completely and there was no pain on palpation of the plantar fascia insertion. The symptoms of the Sever’s disease were still present, although were described as minimal. To this end it was decided to allow the patient to return to sporting activity, providing that he continue to strap his feet and use both of the heel wedges in his sports shoes. At the follow-up appointment two weeks later, it was reported back to the podiatrist that the patient was able to participate in sport although there was mild pain during activity. The following morning there was a slight increase in pain due to the previous activity the day before, but the pain was bearable and not significant enough to warrant exclusion from physical activity. The patient and his mother were advised that it would take some time for the boy to grow out of this condition and that Sever’s disease is a conditioned to be managed and tolerated.

Please note this case study should not be taken as general advice. If you have plantar fasciitis or Sever’s disease you should seek the help of a suitably qualified medical practitioner.

Written by Karl Lockett