Calcaneal Apophysitis (Sever s Disease) a Poorly Identified Pathology: Easy Radiological Evaluation. Poster No.: C-3133 Congress: ECR 2018 Type: Educational Exhibit Authors: P. M. Dautt Medina, M. D. R. R. Iniguez, C. A. Vidal Ruiz, A. D. C. Amador Martínez; MEXICO CITY/MX Keywords: Education and training, Education, MR, Digital radiography, Pediatric, Musculoskeletal system, Musculoskeletal bone DOI: 10.1594/ecr2018/C-3133 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 18
Learning objectives To identify the normal aspects of the secondary ossification center of the calcaneus. To know the causes of heel pain in children and adolescents. To identify the most common radiological findings in Sever s disease. Background Dr. James Warren Sever, an American physician reported in the 20 s a condition characterized by pain in the posterior and inferior region of the heel in very active and/ or overweight children. Posterior heel pain classified as calcaneal apophysitis or Sever's disease is a common musculoskeletal pathology in children. At sports clinics, physicians have reported up to 2-16% of sever disease in active children. It is widely accepted that calcaneal apophysitis is a self-limiting condition related to physiological changes at the calcaneal apophysis in growing children and transition to adolescense. Findings and procedure details The calcaneus and talus bones ossifies by the 3 page 5). rd moth of intrauterine life (Fig. 1 on In healthy infants the calcaneus develops from two different ossification centers, and when they reach the early childhood the apophysis will develop along the posterionferior aspect of the calcaneus (Fig. 2 on page 5). The usual age that the secondary ossification center of the os calcis appears is 9 years, although it may be as early as 7 years (Fig. 3 on page 6), with fusion occurring around 15 years in both female and male patients (Fig. 4 on page 6), occasionally the apophysis may not close until age 16 years in girls and 22 in boys. Page 2 of 18
Calcaneal apophysitisis is a condition that causes pain at the posterior aspect of the heel. It may be presented in children between the ages of 8 to 15 years, when the apophysis of the heel is open. Calcaneal apophysitis is the most common cause of heel pain in the growing athlete. Inflammation of the heel is caused by the traction released in opposite directions between the Achilles tendon and the plantar structures, leading to local congestion (Fig. 5 on page 8). Etiology The etiology of Sever disease is controversial. It is caused by microavulsions at the bone-cartilage junction. It is commonly the result of repetitive motion and overuse during periods of rapid growth. Potential contributing factors include: High-impact sports Improper foot- wear Running on hard surfaces Excessive plantar heel pressures. Shortening of the Achilles tendon. Signs and symptoms Pain at the posterior aspect of the heel: worse during and post activity. limping or toe walking (to avoid ground contact) on the affected limb. Physical examination Page 3 of 18
Physical examination often reveals tenderness and pain at heel when compression is applied on the medial and lateral aspects of the Achilles insertion. Diagnosis is reach by clinical findings, but sometimes X-rays may show other causes heel pain Table 1 on page 13. So it is very important always to make sure that there is no other pathology at the calcaneus that will cause pain. Some examples are shown on (Fig. 6 on page 8). Radiographic features Plain radiograph Foot radiographs can look normal (Fig. 7 on page 9). Increased fragmentation of the ossific nucleus (Fig. 8 on page 10). Sclerotic changes in the secondary ossification center; this finding can be normal in this age (Fig. 9 on page 11). The most reliable radiographic finding is the fragmentation of the secondary ossification nucleus at the calcaneal apophysis. O Ferral noticed that calcaneal fragmentation will improve after apophysis treatment (Fig. 10 on page 12). MRI May show edematous changes within the calcaneal apophysis (Fig. 11 on page 14, Fig. 12 on page 14) T1: hypointensity STIR: bright. Prognosis and treatment Nonoperative treatment includes activity and shoe modifications, padded heel cups, and calf stretches. Patients with persistent symptoms despite activity modification and a stretching program should have other conditions considered. Page 4 of 18
Images for this section: Fig. 1: Obstetric ultrasound. A) Fetus at 10 weeks, the arrow shows non ossified calcaneus. B) Fetus at 23 weeks, the arrow shows the ossified calcaneus. Page 5 of 18
Fig. 2: Foot radiograph lateral view. A) New born and B) 2 years boy, shows ossified calcaneus (white arrow), the calcaneal apophysis is not visualized (yellow dot lines). Fig. 3: Foot radiograph lateral view. A) 7 years old boy and B) 7 years old girl, look the non ossified calcaneal apophysis in boy (blue arrow) and ossified in girl (green arrow), although they are the same age, the ossification center appears before in girls. Page 6 of 18
Fig. 4: Calcaneal lateral view. A) Shows in 10 years old boy, the calcaneal apophysis (arrows) with high density and fragmented, it is not fusionated. B) 10 years old female, the calcaneal apophysis almost complete the fusion. Page 7 of 18
Fig. 5: Drawing of the lateral view of the foot, demonstrates the tensil forces of the Aquilles tendon and plantar fascia, with inflamation of the calcaneal apophysis. Page 8 of 18
Fig. 6: Differential diagnosis of Sever s disease. Calcaneal radiograph, lateral view, two 8 years old boys with heel pain, shows the homogeneous and normal density of the calcaneus ossification center (blue arrows) and the cause of the pain, A) Os trigonum (orange arrowhead) and B) Calcaneus bone cyst (yellow arrow). Page 9 of 18
Fig. 7: Calcaneal radiograph, A) lateral and B) axial view, the feet bones show normal appearance in 7 years old girl, look how the apophysis is regular and has similar density compare with the calcaneus bone. Page 10 of 18
Fig. 8: Drawing of the lateral view of the foot shows the sclerotic appearance of the calcaneus apophysis in Sever s disease. Page 11 of 18
Fig. 9: Drawing of the lateral view of the foot shows the multifragmented appearance of the calcaneus apophysis. Fig. 10: Calcaneus radiograph, lateral view. A) and B) shows the high density of calcaneus apophysis and the fragmented aspect (blue arrows). Page 12 of 18
Table 1: Differential diagnosis of childhood and adolescent heel pain. Page 13 of 18
Fig. 11: Asymptomatic 11 years old boy. Calcaneal MRI, sagittal view. Shows the normal aspect of the calcaneal apophysis and physis. A) PD shows the normal hypointensity of the physis (yellow arrow), the calcaneal apophysis has the same intensity as the rest of the calcaneus (white arrowheads). B)PD FAT SAT, demonstrates the normal hyperdensity of the physis (white arrow) in healthy child, the apophysis and the calcaneus body with the same intensity (white arrowheads). Page 14 of 18
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Fig. 12: 11 years old girl. Calcaneal MRI, DP A) Sagittal view and B) Coronal view, shows the hypointensity and fragmentation of the calcaneal apophysis (yellow arrows). PD FAT SAT C) Sagittal view and D) Coronal view, shows the abnormal hyperdensity of the calcaneus apophysis (yellow arrowheads) in child with heel pain. Page 16 of 18
Conclusion Despite Sever disease is a very common pathology in growing children and young athletes, and clinical findings are most of the time enough to diagnose it, Xrays are extremely important to rule out other causes of heel pain. MRI may be done if X-rays does not show the exact cause of the problem. Personal information Paulette Mariette Dautt Medina MD, Department of Imaging, ABC Medical Center, Mexico City, drapaulettedautt@gmail.com References 1.Lyle J. Micheli MD, and M. Lloyd Ireland, M.D. Prevention and Management of Calcaneal Apophysitis Ill Children: An Overuse Syndrome.Division ofsports Medicine, Children's Hospital Medical Center, Boston, Massachusetts. J Pediatr Orthop. 1987; Vol. 7, No. 1,. 2.Volpon JB, de Carvalho Filho G. Calcaneal apophysitis: a quantitative radiographic evaluation of the secondary ossification center. Arch Orthop Trauma Surg. 2002;122(6):338-41. 3.Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, Rodriguez-Sanz D. Static and dynamic plantar pressures in children with and without sever disease: a case-control study. Phys Ther. 2014;94(6):818-26. 4.Bailey CW, Cannon ML. Sever disease (calcaneal apophysitis). J Am Osteopath Assoc. 2014;114(5):411. 5.Atanda A, Jr., Shah SA, O'Brien K. Osteochondrosis: common causes of pain in growing bones. Am Fam Physician. 2011;83(3):285-91. 6.James AM, Williams CM, Haines TP. "Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review". J Foot Ankle Res. 2013;6(1):16. Page 17 of 18
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