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Sever's Disease (Heel Pain) in Young Athletes
Terra Blatnik, MD, discusses Severs Disease treatment options and when to refer to pediatric sports medicine at St. Louis Children’s Hospital.
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Learn more about Terra Blatnik, MD
Terra Blatnik, MD
Terra Blatnik, MD is a Saint Louis, Missouri based female orthopedic surgeon who is specialized in Sports Medicine.Learn more about Terra Blatnik, MD
Transcription:
Melanie Cole (Host): Sever's disease is one of the more common causes of heel pain in growing children and adolescents. My guest today is Dr. Terra Blatnik. She’s a Washington University pediatric sports medicine physician at St. Louis Children’s Hospital. Dr. Blatnik, explain a little bit about Sever’s disease. What is it?
Dr. Terra Blatnik (Guest): So what Sever’s is that – so kids that are growing have what we call growth plates, or little areas of little cells that are helping your kids get bigger or get their feet – or their feet get bigger. So these little areas of cells are inside all your bones throughout your body as you grow, and so these areas – you have a big area inside of your heel and this area gets really irritated when kids are running and jumping and so it’s basically pain in the growth plate of your heel.
Melanie: Do we know what causes it and if it’s related to sports, which sports are the most problematic?
Dr. Blatnik: So we think it’s probably related to more running and pounding activities, so the more that kids run and jump they start to put more pressure on that heel and the heel starts to get more irritated. So we generally see it more often in kids who wear cleats for sports, so things like soccer and baseball tend to be bigger offenders when it comes to Sever’s.
Melanie: Before we speak about signs and symptoms or even treatment, Dr. Blatnik, as far as prevention, we want our little guys to run around and be involved in sports, but if this can contribute to an injury like that, what would you like other providers to know about counseling their patients or even coaches on ways to prevent this?
Dr. Blatnik: So I think that good shoe wear is a really important thing to talk about, especially when it comes to cleats. Making sure that you’re changing out the shoes often, so when new seasons come around, making sure that they get new shoes. Because the better and more padded the shoes are, the less pressure there’s going to be on that heel, so even just simply choosing a good shoe at the beginning of the season can be helpful for prevention?
Melanie: What are some of the hallmarks? What would send a child to see their pediatrician with that kind of pain?
Dr. Blatnik: So we’ll start to see maybe your child limping when they’re on the field or on the court and then they’ll just start to complain of some vague pain in the back of either their ankle or their heel and both of these are usually the complaints that we get when they come into the office.
Melanie: Is it more common in boys than girls?
Dr. Blatnik: I think we see it pretty equally between the two. You know they both have similar growth plates and so they both get it pretty equally. Now girls do tend to get it potentially a little bit earlier than boys just because of maturity and how fast they mature.
Melanie: And how do you definitively diagnose, what imaging do you use?
Dr. Blatnik: So we generally will do an x-ray just to make sure everything looks okay in the heel. There’s really no good definitive diagnosis necessarily with an x-ray or an MRI. We mostly just go by the signs and symptoms of heel pain and then just noticing that their growth plate is open on an x-ray.
Melanie: Then how is it treated? And what would you like other providers to know about administering that treatment before they would consider referring to a sports medicine specialist?
Dr. Blatnik: Yeah so there’s a couple of basic things that we do for everybody that has Sever’s. So the first thing we do is we have them get some heel cups, and these are little things that you insert into the back of your shoes. We definitely recommend that you get the gel kind that are a bit thicker because it provides sort of the most padding and we have them wear it in both their cleats and in the shoe that they wear to school just so that their heel is always getting some extra padding. The next thing we do is we have them do some stretches so we try to get them to stretch out the back of their leg. So their calf and their Achilles which is all attached back to that heel, so the stretchy or more flexible they are back there, the less it’s going to pull on the growth plate and cause them pain. So we do the heel cup, we do the stretching and then we usually have them ice after they’re done with all of their activities. Even if they’re not overly sore, we still have them ice at the end. And then the last thing is really activity modification. If they’re having pain while they’re out on the field or they’re limping then we have them kind of back down a little bit, maybe avoid some running at a practice or something like that to try and make it feel a little bit better. Now if all of these things – they’re trying all of these things and they’re not getting any better, then that’s generally when we have them come to see us in Sports Medicine or Orthopedics.
Melanie: And then what would you do? Are there certain brace, casts? What would you do to extend that treatment regimen?
Dr. Blatnik: So usually what we’ll do if they’re having pain, particularly on one side, is we will put them into walking boot for a week or two with their heel cups just to kind of take some of the pressure off. It also sort of makes them modify their activities. You know it’s tough to keep kids down. They want to run, jump, and play, even at the playground at school. Even if they’re not necessarily doing - if we’re kind of keeping them out of sport. So the boot will kind of modify their activity and take the pressure off the heel just for a short period of time to try and make it feel a little bit better. And then the other thing is what we’ll often do is we’ll actually send them to physical therapy to work with a therapist on stretching a little bit more through that calf and through that Achilles. They may just need a little bit more than the basic stretches than you can provide in the office.
Melanie: What about return to play? Is that when they’re asymptomatic or are when they’ve still got a little bit of pain? What do you tell them?
Dr. Blatnik: Yeah so this is a little tricky with some of these growth plate things because we will sometimes – we will actually often let them play with just a little bit of pain. So we tell them that if it’s just mild and they’re still able to run and they’re still able to play without limping, then they’re generally okay to keep doing their sports. Now if they’re ever noticed to be limping on the field then we tell the parents they have to stay off mostly because we’re worried that they might injure something else while they’re out there limping.
Melanie: Does it go away as they age and those growth plates finish up their ossification, does it then become something that they don’t have to worry about or does it recur back in adolescent years?
Dr. Blatnik: So usually the pain in the actual heel part will go away once that growth plate closes, so once that part of the foot is done growing. Now if they’re very tight through that calf and Achilles then sometimes it can become more of an Achilles tendonitis as opposed to a Sever’s. They get pain sort of more up the back of the leg as opposed to right in the heel.
Melanie: So you really don’t see this disease in adults per se?
Dr. Blatnik: No, once that growth plate is closed it’s officially not considered Sever’s anymore and you have to think about some other things to do. So that’s why sometimes if they’re on that cusp of growth and we’re not sure if that growth plate’s open, that’s where x-rays can be helpful because once that growth plate’s all closed then it’s no longer Sever’s.
Melanie: Then wrap it up for us Dr. Blatnik, when should a patient be referred to a specialist? What can the physician, the referring physician, expect from your team after referral in so far as communication and what would you like other physicians to know about Sever’s disease?
Dr. Blatnik: Well I would say it’s a super common thing and I think it’s going to come into a primary care office fairly often, and I think if they can try and start with those basics for the patient, a lot of them will get better, so the heel cups, the basic stretching, and some icing. There’s a huge percentage that will get better with just those simple things that you could do. It’s the kids that get more pain that really need to see us, and like we talked about with the boot and the physical therapy and we communicate all that back to the pediatrician through letters and things so they know what’s going on with their patient.
Melanie: Thank you so much for being with us today, Dr. Blatnik, it’s great information for other providers to hear. Thank you again for joining us. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org, that’s stlouischildrens.org. This is Melanie Cole, thanks so much for listening.
Melanie Cole (Host): Sever's disease is one of the more common causes of heel pain in growing children and adolescents. My guest today is Dr. Terra Blatnik. She’s a Washington University pediatric sports medicine physician at St. Louis Children’s Hospital. Dr. Blatnik, explain a little bit about Sever’s disease. What is it?
Dr. Terra Blatnik (Guest): So what Sever’s is that – so kids that are growing have what we call growth plates, or little areas of little cells that are helping your kids get bigger or get their feet – or their feet get bigger. So these little areas of cells are inside all your bones throughout your body as you grow, and so these areas – you have a big area inside of your heel and this area gets really irritated when kids are running and jumping and so it’s basically pain in the growth plate of your heel.
Melanie: Do we know what causes it and if it’s related to sports, which sports are the most problematic?
Dr. Blatnik: So we think it’s probably related to more running and pounding activities, so the more that kids run and jump they start to put more pressure on that heel and the heel starts to get more irritated. So we generally see it more often in kids who wear cleats for sports, so things like soccer and baseball tend to be bigger offenders when it comes to Sever’s.
Melanie: Before we speak about signs and symptoms or even treatment, Dr. Blatnik, as far as prevention, we want our little guys to run around and be involved in sports, but if this can contribute to an injury like that, what would you like other providers to know about counseling their patients or even coaches on ways to prevent this?
Dr. Blatnik: So I think that good shoe wear is a really important thing to talk about, especially when it comes to cleats. Making sure that you’re changing out the shoes often, so when new seasons come around, making sure that they get new shoes. Because the better and more padded the shoes are, the less pressure there’s going to be on that heel, so even just simply choosing a good shoe at the beginning of the season can be helpful for prevention?
Melanie: What are some of the hallmarks? What would send a child to see their pediatrician with that kind of pain?
Dr. Blatnik: So we’ll start to see maybe your child limping when they’re on the field or on the court and then they’ll just start to complain of some vague pain in the back of either their ankle or their heel and both of these are usually the complaints that we get when they come into the office.
Melanie: Is it more common in boys than girls?
Dr. Blatnik: I think we see it pretty equally between the two. You know they both have similar growth plates and so they both get it pretty equally. Now girls do tend to get it potentially a little bit earlier than boys just because of maturity and how fast they mature.
Melanie: And how do you definitively diagnose, what imaging do you use?
Dr. Blatnik: So we generally will do an x-ray just to make sure everything looks okay in the heel. There’s really no good definitive diagnosis necessarily with an x-ray or an MRI. We mostly just go by the signs and symptoms of heel pain and then just noticing that their growth plate is open on an x-ray.
Melanie: Then how is it treated? And what would you like other providers to know about administering that treatment before they would consider referring to a sports medicine specialist?
Dr. Blatnik: Yeah so there’s a couple of basic things that we do for everybody that has Sever’s. So the first thing we do is we have them get some heel cups, and these are little things that you insert into the back of your shoes. We definitely recommend that you get the gel kind that are a bit thicker because it provides sort of the most padding and we have them wear it in both their cleats and in the shoe that they wear to school just so that their heel is always getting some extra padding. The next thing we do is we have them do some stretches so we try to get them to stretch out the back of their leg. So their calf and their Achilles which is all attached back to that heel, so the stretchy or more flexible they are back there, the less it’s going to pull on the growth plate and cause them pain. So we do the heel cup, we do the stretching and then we usually have them ice after they’re done with all of their activities. Even if they’re not overly sore, we still have them ice at the end. And then the last thing is really activity modification. If they’re having pain while they’re out on the field or they’re limping then we have them kind of back down a little bit, maybe avoid some running at a practice or something like that to try and make it feel a little bit better. Now if all of these things – they’re trying all of these things and they’re not getting any better, then that’s generally when we have them come to see us in Sports Medicine or Orthopedics.
Melanie: And then what would you do? Are there certain brace, casts? What would you do to extend that treatment regimen?
Dr. Blatnik: So usually what we’ll do if they’re having pain, particularly on one side, is we will put them into walking boot for a week or two with their heel cups just to kind of take some of the pressure off. It also sort of makes them modify their activities. You know it’s tough to keep kids down. They want to run, jump, and play, even at the playground at school. Even if they’re not necessarily doing - if we’re kind of keeping them out of sport. So the boot will kind of modify their activity and take the pressure off the heel just for a short period of time to try and make it feel a little bit better. And then the other thing is what we’ll often do is we’ll actually send them to physical therapy to work with a therapist on stretching a little bit more through that calf and through that Achilles. They may just need a little bit more than the basic stretches than you can provide in the office.
Melanie: What about return to play? Is that when they’re asymptomatic or are when they’ve still got a little bit of pain? What do you tell them?
Dr. Blatnik: Yeah so this is a little tricky with some of these growth plate things because we will sometimes – we will actually often let them play with just a little bit of pain. So we tell them that if it’s just mild and they’re still able to run and they’re still able to play without limping, then they’re generally okay to keep doing their sports. Now if they’re ever noticed to be limping on the field then we tell the parents they have to stay off mostly because we’re worried that they might injure something else while they’re out there limping.
Melanie: Does it go away as they age and those growth plates finish up their ossification, does it then become something that they don’t have to worry about or does it recur back in adolescent years?
Dr. Blatnik: So usually the pain in the actual heel part will go away once that growth plate closes, so once that part of the foot is done growing. Now if they’re very tight through that calf and Achilles then sometimes it can become more of an Achilles tendonitis as opposed to a Sever’s. They get pain sort of more up the back of the leg as opposed to right in the heel.
Melanie: So you really don’t see this disease in adults per se?
Dr. Blatnik: No, once that growth plate is closed it’s officially not considered Sever’s anymore and you have to think about some other things to do. So that’s why sometimes if they’re on that cusp of growth and we’re not sure if that growth plate’s open, that’s where x-rays can be helpful because once that growth plate’s all closed then it’s no longer Sever’s.
Melanie: Then wrap it up for us Dr. Blatnik, when should a patient be referred to a specialist? What can the physician, the referring physician, expect from your team after referral in so far as communication and what would you like other physicians to know about Sever’s disease?
Dr. Blatnik: Well I would say it’s a super common thing and I think it’s going to come into a primary care office fairly often, and I think if they can try and start with those basics for the patient, a lot of them will get better, so the heel cups, the basic stretching, and some icing. There’s a huge percentage that will get better with just those simple things that you could do. It’s the kids that get more pain that really need to see us, and like we talked about with the boot and the physical therapy and we communicate all that back to the pediatrician through letters and things so they know what’s going on with their patient.
Melanie: Thank you so much for being with us today, Dr. Blatnik, it’s great information for other providers to hear. Thank you again for joining us. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org, that’s stlouischildrens.org. This is Melanie Cole, thanks so much for listening.