Pain in children is often attributed to growing pains, however true growing pains are in fact very rare. In our physio clinics in Surrey, we see a lot of children with Sever’s disease – pain in the back of the foot. In our blog we cover what Sever’s disease actually is, common misdiagnoses, causes, symptoms and treatment.
The growing child has several tissue imbalances over the course of growth. This is not a linear pattern and depends on hormones and other factors, like diet and sport. This is poorly understood outside of the world of paediatric physio or medicine. Generalist medical professionals are not trained in paediatric growth and development, and many do not know the common conditions that cause children’s pain. Many children suffer with pain when there is often a very simple diagnosis, and treatment can be quick and easy – but this needs to be done by someone who has addition training in ‘child growth.’
What is Sever’s disease?
Sever’s disease is very common in children. It is thought, at least 50% of children have it but it’s the impact on them and other risk factors that determine how much it affects them or how quickly it resolves.
Sever’s disease is pain in the back of the foot, heel, under the foot or up into the calf muscle. It is ‘inflammation of the growth plate’ in the calcaneum – the calcaneum is the bone at the back of the foot – the heel. Growth plates are only found in a growing bone (once the growth plate closes, then Sever’s cannot come back) and the whole time the growth plate is open/active the child can develop Sever’s disease or have a relapse. The growth plates are open in the heel until mid-teens in females and later in males.
Having a primary episode of Sever’s and not receiving the appropriate care is a big predictor for reoccurrence, or other growth plate problems – there are lots! It is not unheard of to have it for several years – especially when treated incorrectly or develop other pains in the knees and hips.
An x-ray is not required to diagnose Sever’s – it is not seen on imaging.
Misdiagnoses
Sever’s is commonly misdiagnosed. Many diagnose adult conditions or even ‘growing pains’. Such conditions include plantar fasciitis, ankle sprains, Achilles tendonitis, or tendinopathies. These conditions never really occur in a child, unless under exceptional circumstances.
What age does Sever’s disease impact children?
Sever’s generally occurs around the pre-teen period, but can also be later, especially boys. Girls can suffer younger than boys and can suffer as young as 6 years old, but more commonly from 8 years up to about 11-12 years. Boys tend to be later with the growth phase and typical pattern of onset is 10-14yrs, however, not all children follow these rules.
Every bone in the body grows and reaches skeletal maturity at different times and rates. There is a general pattern known to those that work with children, but a specialist can calculate this, depending on an appropriate assessment of the child.
Symptoms of Sever’s disease: Early treatment is key
The pain can be very uncomfortable – even ‘disabling’ normal function on intermittent or on a day-to-day basis. It can come on suddenly or sometimes it is triggered by a bit of another twist, or jump. There is often no cause’ and why it’s often just labelled as a ‘growing pain.’ The child may limp or have pains if it’s in one foot, but it can also occur in both, and these stop them doing things they love.
It can be around for a few weeks and then go, but then comes back again, often getting worse at each episode. It can get better over times of more rest – e.g. school holidays but comes back quickly with the return to the normal routine. There are many factors a specialist will consider. This is typically when a paediatric physio will be asked to assess the child. Unfortunately, this is when it is harder and takes longer to treat. Many parents wish they had seen the right therapist at the start because many of the more complicated and severe issues associated with Sever’s would have almost certainly been avoided.
The severity of symptoms is dictated by many variables and that is the job of a paediatric therapist to unpick and come up with the correct treatment plan and order. There is not a one size fits all. It must be tailored to the child and the maturation of their bones and their risk factors.
In severe cases (only 2-5%), these children will need further support of the wider paediatric team and Orthopaedic doctors are consulted to determine if a period of plaster casts or plaster walking boots (4-6 weeks) is needed before paediatric physio can be initiated. The paediatric physio can determine this and normally orthopaedic input is not otherwise required.
Causes of Sever’s disease
Common presentations are across all profile of children, including both sporty and less sporty children. For example, a child may have just started a new sport, had a change of footwear, seen an increase or change in training, moved up a level or age group, or returned from a holiday or a period away from less activity. There is often, but not always, a growth spurt of the feet or height, and sometimes body weight. It can even occur when the school rotates at half term into another activity, e.g. the transition into summer athletics is common. Others suffer who are not the ‘sporty, active type’ and perhaps have done more activity than they are used too and this is the trigger.
Sever’s disease is sometimes described for this reason as an ‘Overuse injury’.
Treatment for Sever’s disease
The growth plate in the heel becomes inflamed due to a variety of reasons (as described above). Other causes can be the type of footwear or perhaps having a flat foot.
Therefore, assessment determines the course of treatment. Specialist input is required when cases are more advanced, or to prevent the more severe cases. This is where many assess or treat Sever’s disease incorrectly and the child either doesn’t get better or does but has repeated relapses over the coming years, all because the correct treatment and knowledge has not been applied. Paediatric Physios see this pattern frequently.
Basics include anti-inflammatory treatments which range from rest, ice, NSAIDs and footwear advice. There will be a biomechanical imbalance in the bone and soft tissues, and this is addressed with exercises for the relevant areas. A child will not grow under predictable patterns, therefore closely monitoring all the issues identified along with the treatment plan is important. These will be adjusted to accommodate growth and because of this the child and family work very closely with the paediatric physio to try and ensure a smoother recovery ‘back to normal’ and a faster return to sport. However, ‘flare ups’ can be a natural part of the treatment processes and again where the specialist will know and support any worried child or parent.
If a child has pain, this is highly likely not a growing pain and there is often a diagnosis, which requires assessment and appropriate treatment. We recommend seeing a paediatric physio (not a physio who can treat children) because they are highly trained to then refer to other specialists if needed. If you would like to speak to a physiotherapist then please get in touch. Book an appointment with a physio online.
