Sever's Disease Rehabilitation Protocol: Pediatric Heel Pain

This protocol outlines a comprehensive physical therapy rehabilitation program for Sever's Disease, also known as calcaneal apophysitis. It is designed to guide treatment progression from initial pain management through a gradual return to activity.

Pathophysiology

Sever's Disease is a common cause of heel pain in active children and adolescents, typically between the ages of 8 and 15. It is an overuse injury affecting the apophysis (growth plate) of the calcaneus (heel bone). Rapid bone growth during puberty, combined with repetitive traction forces from the Achilles tendon, can lead to inflammation and pain at the growth plate. Contributing factors include increased activity levels, inadequate footwear, tight calf muscles, and excessive pronation. Unlike fractures, Sever's Disease doesn't involve actual bone fracture but rather irritation of the growth plate.

Phase I: Protection (Pain and Inflammation Control)

The primary goals during this phase are to reduce pain, inflammation, and protect the injured apophysis. This phase typically lasts 1-4 weeks, depending on symptom severity.

• Activity Modification:
  • Reduce or eliminate activities that aggravate pain, such as running, jumping, and prolonged standing.
  • Cross-training activities (e.g., swimming, cycling) are encouraged to maintain fitness as tolerated.
• Pain Management:
  • RICE: Rest, Ice (15-20 minutes every 2-3 hours), Compression (with elastic bandage), and Elevation.
  • NSAIDs: Over-the-counter nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen) may be used as directed by a physician.
  • Pain-free range of motion: Ankle plantarflexion, dorsiflexion, inversion, and eversion.
• Gastrocnemius and Soleus Stretching:
  • Gentle stretching of the calf muscles (gastrocnemius and soleus) to improve flexibility. Hold each stretch for 30 seconds, repeat 3-5 times, 2-3 times per day. Emphasis should be on pain free stretching.
  • Perform both straight-knee (gastrocnemius) and bent-knee (soleus) stretches.
• Orthotics/Heel Lifts:
  • Temporary use of heel lifts (1/4 to 1/2 inch) may reduce stress on the Achilles tendon and apophysis.
  • Custom or prefabricated orthotics may be considered, particularly if excessive pronation is present.
• Patient Education:
  • Educate the patient and parents about the condition, its causes, and the importance of adherence to the rehabilitation program.
  • Proper footwear, including supportive shoes with good cushioning, should be emphasized.

Phase II: Loading (Progressive Strengthening and Flexibility)

This phase focuses on gradually increasing the load on the calcaneus and improving strength, flexibility, and proprioception. This phase typically lasts 2-4 weeks.

• Progressive Calf Stretching:
  • Continue calf stretching, gradually increasing the intensity and duration.
  • Consider the use of a slant board to deepen the stretch.
• Ankle Strengthening Exercises:
  • Isometric Ankle Exercises: Dorsiflexion, plantarflexion, inversion, and eversion against resistance (e.g., wall, resistance band). Hold for 5-10 seconds, repeat 10-15 times.
  • TheraBand Exercises: Dorsiflexion, plantarflexion, inversion, and eversion using TheraBand resistance. Progress resistance as tolerated.
  • Calf Raises: Begin with bilateral calf raises and progress to single-leg calf raises as tolerated. Focus on controlled movement and full range of motion.
• Proprioceptive Exercises:
  • Balance Training: Begin with standing on a stable surface and progress to standing on an unstable surface (e.g., balance board, foam pad).
  • Single-Leg Stance: Practice maintaining balance on the affected leg.
• Core Strengthening:
  • Engage in core strengthening exercises to improve overall stability and reduce stress on the lower extremities. Examples include planks, bridges, and abdominal crunches.
• Gradual Return to Activity:
  • Begin with low-impact activities, such as walking and swimming, gradually increasing the duration and intensity.
  • Monitor symptoms closely and avoid activities that exacerbate pain.

Phase III: Return to Function (Sport-Specific Training)

This phase aims to return the patient to their previous level of activity without pain or limitations. This phase typically lasts 2-4 weeks.

• Sport-Specific Exercises:
  • Incorporate exercises that mimic the specific movements required for the patient's sport or activity.
  • Examples: agility drills (cone drills, shuttle runs), jumping exercises (plyometrics), and sport-specific skills training.
• Progressive Loading:
  • Gradually increase the intensity and duration of sport-specific activities.
  • Monitor symptoms closely and adjust the program accordingly.
• Plyometric Exercises:
  • Initiate plyometric exercises with low impact activities such as jumping rope and progress to box jumps and bounding.
• Functional Testing:
  • Before returning to full activity, perform functional tests to assess strength, endurance, and agility. Examples include single-leg hop test, vertical jump test, and agility tests.
• Maintenance Program:
  • Continue calf stretching and strengthening exercises to prevent recurrence.
  • Proper footwear and orthotic use should be maintained as needed.
  • Encourage ongoing awareness of body mechanics and activity modification as necessary.

Common Special Tests

• Squeeze Test: Compression of the calcaneus elicits pain at the apophysis.
• Palpation: Direct palpation of the calcaneal apophysis reproduces pain.
• Dorsiflexion Test: Passive dorsiflexion of the ankle with knee extension increases stress on the Achilles tendon and may elicit pain at the apophysis.

Important Note: This protocol is a general guideline and should be adapted to meet the individual needs of each patient. Close communication between the physical therapist, physician, patient, and parents is essential for successful rehabilitation.