Sever's Disease Rehabilitation Protocol

This protocol outlines the rehabilitation program for patients diagnosed with Sever's Disease (calcaneal apophysitis). It is designed to guide physical therapists in providing evidence-based care and facilitating a safe return to activity. This protocol should be adapted based on individual patient presentation and response to treatment.

I. Clinical Presentation

Sever's disease is a common cause of heel pain in adolescents, typically affecting children between the ages of 8 and 15, during periods of rapid growth. Key clinical findings include:

• Pain: Localized to the posterior heel, particularly at the calcaneal apophysis (growth plate).
• Aggravating Factors: Increased pain with activity, especially running, jumping, and prolonged standing. Pain is often relieved by rest.
• Tenderness: Direct palpation of the calcaneal apophysis elicits significant tenderness.
• Limited Ankle Dorsiflexion: Often associated with tight Achilles tendon and gastrocnemius/soleus muscles.
• Positive Squeeze Test: Pain reproduced by squeezing the calcaneus.
• Gait Abnormalities: May present with antalgic gait, favoring forefoot weight-bearing to avoid heel strike.

II. Rehabilitation Phases

Rehabilitation progresses through phases based on pain levels, range of motion, and functional abilities. Progression criteria must be met before advancing to the next phase.

Phase 1: Pain Management and Inflammation Control (1-2 Weeks)

Goals: Reduce pain, inflammation, and protect the healing tissues.

• Activity Modification: Avoid aggravating activities (running, jumping) until pain subsides. Recommend alternative low-impact activities like swimming or cycling.
• Rest: Encourage rest and limited weight-bearing as needed.
• Ice: Apply ice packs to the affected area for 15-20 minutes, 3-4 times daily.
• Compression: Use a compressive bandage to reduce swelling.
• Elevation: Elevate the leg to reduce edema.
• Gentle Stretching:
  • Towel Calf Stretch: Gentle dorsiflexion using a towel.

Phase 2: Restoring Range of Motion and Flexibility (2-4 Weeks)

Goals: Improve ankle range of motion, increase flexibility of the calf muscles, and begin to restore strength.

• Stretching:
  • Gastrocnemius Stretch: Straight-leg calf stretch.
  • Soleus Stretch: Bent-knee calf stretch.
  • Plantar Fascia Stretch: Toe pulls and stretches.
• Ankle Mobilization: Gentle ankle joint mobilization to improve dorsiflexion.
• Strengthening (Isometric):
  • Isometric Ankle Dorsiflexion: Pressing foot against a wall.
  • Isometric Ankle Plantarflexion: Pushing foot against a wall.

Phase 3: Strengthening and Proprioception (4-6 Weeks)

Goals: Enhance lower extremity strength, improve proprioception, and gradually return to sport-specific activities.

• Strengthening (Isotonic):
  • Heel Raises: Start with bilateral, progress to unilateral.
  • Toe Raises: Strengthening tibialis anterior.
  • Resisted Dorsiflexion/Plantarflexion/Inversion/Eversion using resistance bands.
  • Calf Raises on Incline: Increased ROM and muscle activation.
• Proprioception:
  • Single-Leg Stance: Maintain balance on affected leg.
  • Balance Board/Wobble Board Exercises: Progress from bilateral to unilateral.
  • Star Excursion Balance Test: Assessing and improving dynamic balance.
• Cross Training: Continue low-impact activities to maintain cardiovascular fitness.

Phase 4: Return to Activity (6-8+ Weeks)

Goals: Return to full activity participation without pain or limitations.

• Gradual Return to Sport: Begin with light jogging, gradually increasing distance and intensity.
• Plyometrics: Introduce jumping and landing exercises. Start with low-impact and progress to high-impact.
  • Jump Rope
  • Box Jumps (Low height)
• Sport-Specific Drills: Incorporate drills that mimic sport activities.
• Maintain Flexibility and Strength: Continue stretching and strengthening exercises as maintenance.

III. Return to Function Criteria

The following criteria must be met before returning to full activity:

• Pain-Free Palpation: No pain on palpation of the calcaneal apophysis.
• Full Range of Motion: Equal ankle dorsiflexion compared to the unaffected side.
• Symmetrical Strength: 80% or greater strength compared to the unaffected side. Measured using manual muscle testing or dynamometry.
• Successful Completion of Functional Testing: Able to perform sport-specific activities (running, jumping, cutting) without pain or limitations. Example Functional tests include single leg hop test for distance and timed hop tests.
• Physician Clearance: Obtain clearance from a physician or qualified healthcare provider.

This protocol provides a framework for rehabilitation. Individualization of treatment is essential to achieve optimal outcomes. Continued monitoring and communication with the patient are crucial for successful recovery.