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R E V I E W Open Access
“Effectiveness of interventions in reducing pain
and maintaining physical activity in children and
adolescents with calcaneal apophysitis (Sever’s
disease): a systematic review”
Alicia M James
1,3*
, Cylie M Williams
2,3
and Terry P Haines
2,3
Abstract
Background: Calcaneal apophysitis, also commonly known as sever’s disease, is a condition seen in children usually
aged between 8–15 years. Conservative therapies, such as taping, heel lifts and orthotic intervention are accepted
management practices for calcaneal apophysitis, though there is very little high quality research examining the
efficacy of such treatment modalities. Previous narrative literature reviews and opinion pieces provide some
evidence for the use of heel raises or orthoses. The aim of this manuscript was to complete a systemic review on
the treatment options for calcaneal apophysitis as measured by pain reduction and maintenance of physical
activity.
Methods: A search strategy completed by two reviewers examined nine databases from inception to May 2012.
Search terms included heel pain, children, adolescent, calcaneal apophysitis, sever’s disease, treatment, and
management (full text publications, human studies). Systematic reviews, randomised control trials, case series, and
case studies were included. The reference lists of the selected articles were also examined. The methodology,
quality and risk of bias was examined and assessed using the PEDro scale.
Results: Nine articles were retrieved including three clinical trials involving randomisation, two case series, two
retrospective case reviews, and two case reports. Effect size calculations and a meta analysis were unable to be
completed due to the limited data reported within the literature. Numerous treatment options were reported
throughout the literature, though few were examined against a control or alternate treatment option in
well-designed trials. The limited evidence indicated that orthoses provided greater short-term pain relief than heel
raises. Health practitioners should view these results with caution, as there were apparent methodological problems
with the employed study design and limited follow-up of participants.
Conclusion: There is limited evidence to support the use of heel raises and orthoses for children who have heel
pain related to calcaneal apophysitis. Further research is needed to generate higher quality evidence with larger
sample sizes, and validated measures of pain and function to establish effective treatment approaches for children
with calcaneal apophysitis.
* Correspondence: AliciaJames@phcn.vic.gov.au
1
Podiatry, Peninsula Health Service, Melbourne, Australia
3
Monash University, Melbourne, Australia
Full list of author information is available at the end of the article
JOURNAL OF FOOT
AND ANKLE RESEARCH
© 2013 James et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
James et al. Journal of Foot and Ankle Research 2013, 6:16
http://www.jfootankleres.com/content/6/1/16
Background
Early in the 20th century, Sever reported a condition
characterised by pain in the posterior and inferior region
of the heel in very active and/or overweight children.
This was reported to be characterised by the enlarge-
ment of the epiphyseal line of the ossific nucleus of the
calcaneus on radiographic examination, with cloudiness
and obliteration of the epiphyseal line [1]. Over a decade
later, an explanation for the cause of calcaneal apo-
physitis was posited by Lewin [2], who argued that it
was inflammation caused by traction in opposite direc-
tions between the achilles tendon and the plantar fascia
and aponeurosis.
Posterior heel pain classified as calcaneal apophysitis
or sever’s disease may be a common musculoskeletal in-
jury in children as this condition has been reported to
account for between 2% - 16% of presentation at sports
clinics [3-5]. Calcaneal apophysitis is reported as a self
limiting condition [6], usually presenting between the
ages of 8–15 years [7,8], but has been observed in chil-
dren as young as six [9]. The pain related to this inflam-
mation is though to cease after fusion of the calcaneus
[1]. However, no studies have yet reported the incidence
or prevalence of this condition in the general population
[10]. Pain with walking and sport is often reported in
this condition and is a cause of concern for both parent
and child. The physical activity reported to produce the
highest levels of pain include frequent running and
jumping such as soccer [11]. In rare cases, it has been
reported that untreated calcaneal apophysitis can cause
calcaneal apophyseal avulsion fractures [12]. Beyond the
pain and physical disability associated with calcaneal
apophysitis, children with this condition have also been
found to have lower ‘Happiness’and lower ‘Sport/Phys-
ical Function’subscale scores from the Paediatric Ortho-
paedic Surgeons of North America ‘Musculoskeletal
Quality of Life’questionnaire (n = 67), when compared
to children without calcaneal apophysitis (control group
n = 236) [13].
The recommended treatment options for calcaneal
apophysitis are varied. Only one literature review has
examined literature pertaining to calcaneal apophysitis
between 2008–2011, this review finding that there is no
criterion based treatment path and recommended
further evaluation of treatment methods [14]. Narrative
literature reviews [15,16] have recommended the
following treatment options: rest or cessation of sport
[17-23], heel lift, orthoses, mobilisation [1,17,19,21,
23-27] stretching or strengthening exercise programs
[1,2,17,19-21,23,24,28], padding for shock absorption or
taping of heel [1,2,19,27-31], ultrasound/pharmaceutical
prescriptions/ice [3,11,19-21], immobilisation casting
and crutches [11,25,26,32] and footwear prescription
with appropriate support and cushioning [33]. This
review aims to synthesise the available evidence on the
efficacy of treatment approaches for maintaining phys-
ical activity and reducing pain (short and long term) for
children with calcaneal apophysitis.
Method
Development of a clinical question
The clinical question for this systematic review was gen-
erated using the PICO format [34]. It was: ‘In patients
with calcaneal apophysitis (sever’s disease) is there an
effective treatment that relieves pain and maintains
physical activity?
This question was separated into search terms and
nine electronic databases were searched (Medline,
CINAHL, Pubmed, Web of Science, Scopus, Ebscohost,
Google scholar, Physiotherapy Evidence Database (PE-
Dro) and the Cochrane Library) from the earliest avail-
able date until May 2012 using key word search terms
(Table 1). Given the small amount of literature on this
condition, terms for the disease and generic treatment
were searched without limiting the search using specific
treatment or outcome terms.
Search strategy results
Two authors (AJ and CW) independently reviewed all
the retrieved studies against the eligibility criteria
(Table 2). Full articles were obtained where there was
uncertainty from the abstract. The reference list of each
of the articles was also reviewed and any articles meeting
the inclusion criteria were also included.
Four hundred and eight articles were extracted; from
this three hundred and sixty two were excluded as per
the inclusion/exclusion criteria. Following review of the
full text, eleven texts were found to be significant, nine
publications were included within the review (Figure 1).
Two publications were excluded: a systematic review
that was not published in a peer review journal which
examined the literature between 2008–2011 [14], and a
masters thesis examining treatment options which was
written in Spanish [35].
Data extraction
All articles included within the review underwent meth-
odological assessment using the PEDro scale. This scale
[36] was used by the two authors independently, who
following this, met in person to discuss and resolve any
disagreement. Articles relating to treatment of calcaneal
apophysitis were also classified into levels of evidence
using criteria set out by the Oxford Centre for Evidence
Medicine [37]. This system recommends that the most
appropriate research to guide treatment are systematic
reviews of randomised control trials (Level 1), ran-
domised control trials (Level 2), non-randomised con-
trolled cohort/follow up study (Level 3), cohort studies
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and/or case series (Level 4) and mechanism based rea-
soning (Level 5) [37].
Results
Description of studies
A summary of the articles identified has been compiled
within Table 3. Three articles describing clinical trials in-
volving randomisation (Level 2) were found, of which
two compared heel raises to orthoses in a cross over
design of randomisation [38,39] while the other article
described comparison of orthoses to no treatment (con-
trol) [40]. The same author group conducted all three
studies. An article describing a cohort study (Level 3)
was also found which reported on many concurrent
treatment modalities [41]. The remaining four articles
were case series studies (Level 4), which also used many
concurrent treatment modalities [17,42-45]. The major-
ity of studies were found to have low scores on the
PEDro scale (Table 4).
Meta analysis/pooling of data
A meta analysis of the selected nine articles was not com-
pleted as pooling was restricted by inadequate statistical
analysis/reporting, missing data and dissimilar interven-
tions. Three author groups [40,42,45] were contacted by
email and requested to provide outcome measure data
clarification in a format that would allow for meta analysis,
however this was unable to be garnered.
The treatment recommendations from this review
were grouped into two general categories for presenta-
tion of results:
i) Strategies aimed at minimising the inflammation
process, minimising pain and promoting the healing
process. These included, modified rest or cessation
of sport [41,43], pharmaceuticals [44] and/or ice
[41,43,44].
ii) Mechanical strategies aimed at modifying
biomechanical factors that may contribute to
calcaneal apophysitis. These included the use of heel
raises [17,38,39,41,44], taping/padding [42,45],
orthoses [17,38-41], and stretching of the
gastrocnemius / soleus / achilles tendon complex
[17,41,43,44].
Minimising the inflammation process
The use of ice, stretching and rest or restriction of activ-
ities has been incorporated in the majority of studies
[41,43,44]. These were commonly provided, as a cluster
of treatments and the individual effectiveness of each
modality have not been examined within the literature.
Even when provided as a cluster of treatments, none of
the studies identified in this review reported the results
of the effectiveness of this treatment on pain or physical
activity levels.
Table 1 Search strategy results
Search terms Medline CINAHL Web of Science Pub Med Scopus Ebsco host PEDRO Cochrane library
Heel pain and children 23 18 111 189 284 69 0 4
Heel pain and Adolescent 3 6 22 195 288 108 0 0
Calcaneal apoph* 37 10 29 26 39 39 0 0
Calc* apoph* 22 9 34 32 54 49 3 0
Sever’s disease 31 23 25 26 37 65 0 0
Calcaneal apoph* and treatment 7 3 14 19 21 4 0 0
Sever’s disease and Treat* 7 7 8 14 16 14 0 0
Calcaneal apoph* and manage* 6 0 7 6 4 2 0 0
* truncation character that allows the retrieval of varying endings of your search term.
Table 2 Inclusion/exclusion criteria
Inclusion criteria Exclusion criteria
Design: •Articles not published
in English
•RCT •Articles not
including treatment
•Clinical trial •Non peer
reviewed publications
•Case report, •Author opinion
•Case series
Participants:
•Children aged 6–15 years
•Diagnosis of CA/Sever’s disease
Intervention:
•Orthoses
•Heel lifts
•Stretching
•Icing
•Strapping
•Other treatment modalities
Outcome measure:
•Pain
•Physical activity (sporting activities)
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Non steroidal anti-inflammatory drugs (NSAIDS)
There was one study within the review that incorporated
the use of NSAIDS for this condition. This article
reported the effectiveness of a topical NSAIDS in the re-
duction of pain in a single case report . While the use of
this particular topical NSAIDS, Ketroprofen, was contra-
indicated in children under the age of 12 [47] this iso-
lated case was conducted with medical involvement and
was well monitored for adverse effects. There were
confounding factors reported throughout this study, as
the single participant also had hot/cold therapy and mo-
bilisation. It is not known how long the impact of this
therapy lasted, nor is it known if the decrease in pain
was achieved through the application of topical NSAID
or from the physical therapy modalities.
Modifying biomechanical factors
Taping
The use of taping alone [42] was only reported in one
pre-post intervention, (n = 10) case series. This modality
was reported by the authors to be effective in the acute
and immediate (no time frame was reported) relief of
pain with p = 001. The measurement of pain was by an
11-point ordinal scale with 0 representing ‘absolutely no
pain’and 10 representing ‘worst imaginable pain’.The
wording of the pain question was not provided so it is
unclear which domain within the construct of pain was
being measured.
The use of padding and strapping was utilised [45] in
one case series, (n = 11) where n = 5 had a diagnosis of
calcaneal apophysitis. The authors reported this modality
to be effective in decreasing pain during and post activ-
ity across a time period of 1 month with p = <0.01. As
this study also included adults who had posterior heel
pain, the resultant pain relief from this treatment should
be cautiously regarded.
Orthoses
The use of orthotics has been reported within a number
of studies and for the purposes of this review, all of the
devices that were custom made, moulded around the
heel, with or without an arch support are termed as
orthoses. There were five publications identified in this
review [17,38-41], which examined the efficacy of orth-
oses either in comparison to heel lifts or no intervention.
Two of these described retrospective case note reviews,
while three other publications described two randomised
control trials.
In the retrospective case studies examining use of
orthoses [17,41], the type or style of orthoses used was
not described and specific data and/or statistical analysis
that would permit evaluation of the efficacy of this inter-
vention were not provided.
The remaining three papers reported the results of
two randomised control trials, conducted by the same
investigators. The first randomised trial [38,39] was a
cross-over design with a sample size of 44. There was an
initial two-week observation period with no interven-
tion, followed by a four-week ‘intervention’period where
participants were randomly assigned to orthoses or heel
Figure 1 Review of literature.
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Table 3 Summary of studies included
First Author,
Year
Study
design
Country/
Population
Diagnosis * Sample
size
Treatments used Outcome
measurement
Assessment
time frame
Effect of
intervention
Level of
evidence [37]
Rest Ice Stretch Taping Heel
Lifts
Orthoses Other
Hunt,
2007 [42]
Case series USA Yes 11 XX X ✓XX X 11 point pain scale 5 minutes P = .001 4
9 male, 2
female
Aged 9-14
Kvist,
1991 [41]
Retrospective
case review
Finland Yes 67 ✓✓ ✓ X✓✓ ✓ Pain
**
16 weeks Not reported 3
36 Male (Massage) Activity history
31 female
Aged 8-16
Leri, 2004
[43]
Case Report USA Yes 1 ✓✓ ✓ XX X ✓Pain
**
1 week Not reported 4
1 Male
Age 11
Micheli
1987 [17]
Retrospective
case review
Sweden Yes 85 XX ✓X✓✓ ✓ Symptomatic relief 48 weeks Not reported 3
64 Male mobil/activity
mod
Time
21 Female Activity history
7-15 years
Perhamre
2011 [38]
Randomised
Trial
Sweden Yes 35 XX X X ✓✓ XBorg CR-10 Pain 8 weeks IQR 2
35 males P vaues
Aged
9–15 years
Perhamre
2011b [40]
Randomised
Trial
Sweden Yes 30 XX X X X ✓XBorg CR-10-Pain 4 weeks P values 2
30, 45 or 50
children
Endgstrom Activity level
Aged
9–15 years
Perhamre
2010c [39]
Randomised
control trial
Sweden Yes 51 XX X X ✓✓ XBorg CR-10- Pain 26 weeks P Values 2
51 males
Aged 9-15
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Table 3 Summary of studies included (Continued)
White, Case report USA Yes 1 ✓✓ ✓ X✓X✓VAS Pain 18 days Not reported 4
2006 [44] 1 female (NSAIDS, Heat,
mobilised)
LEFS
***
Aged 8 Strength
ROM
Wooten ,
1990 [45]
Case Series USA Yes 5 X X X Tapping
padding
Pain
**
4 weeks P Values 4
5X✓✓ ROM
* Diagnosis of calcaneal apophysitis confirmed by medial and lateral compression (calcaneal squeeze test).
**The pain scale utilised was not disclosed.
***LEFS- Lower extremity functional screen.
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Table 4 PEDro scores of included studies
First
Author
and Year
Study
design
Eligibility
criteria
specified.
Random
allocation
Concealed
allocation
Group
similar at
baseline
Participant
blinding
Therapist
blinding
Assessor
blinding
<15%
dropouts
Intention to
treat
analysis
Between group
difference
reported
Point estimate and
variability reported
Total
Hunt,
2007 [42]
Case series Yes XX ✓XXX✓✓ XX 3/10
Kvist, 1991
[41]
Retrospective
case review
yes X X X X X X X N/A X X 0/10
Leri, 2004
[43]
Case Report No XX X X X XX✓XX 1/10
Micheli
1987 [17]
Retrospective
case review
yes XX X X X XXX X X 0/10
Perhamre
2011a [38]
Randomised
Trial
Yes ✓X* X X X X ✓X✓✓ 4/10
Perhamre
2011b [39]
Randomised
Trial
Yes ✓X* ✓XXX✓X✓✓ 5/10
Perhamre
2011c [40]
Randomised
trial
Yes ✓XX X XX✓X✓✓ 4/10
White,
2006 [44]
Case report No XX X X X XX✓XX 1/10
Wooten ,
1990 [45]
Case Series Yes XX X X X XX✓X✓2/10
♦Concealment was reported to be tickets concealed within a box. Minimum concealment is recommended to be as sequential numbered, opaque sealed envelope to minimise biases and confounding variables [46].
Criterion 1- Subjects were randomly allocated to groups.
Criterion 2- Allocation was concealed.
Criterion 3- The groups were similar at baseline regarding the most important prognostic indicators.
Criterion 4- There was blinding of all subjects.
Criterion 5- There was blinding of all therapists who administered the therapy.
Criterion 6- There was blinding of all assessors who measured at least one key outcome.
Criterion 7- Measure of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups.
Criterion 8- All subjects for whom outcome measures were available received treatment or control condition as allocated or when this was not the case, data for at least one key outcome was analysed by ’intention
to treat‘.
Criterion 9- The results of between group statistical comparisons are reported for at least one key outcome.
Criterion 10- The study provides both point measures and measures of variability for at least one key outcome.
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raise interventions. This was followed by another two-
week period with no intervention, and another four-
week ‘intervention’period with the opposite intervention
compared to the first intervention period. Finally, there
was another two-week period with no intervention. At
the end of this trial, the investigators allowed partici-
pants to choose which intervention they preferred and
then re-assessed the participants twelve weeks later.
Outcomes in this research were measured at the end of
each ‘no intervention’and ‘intervention’period. While
there was no control group within this study, the cross-
over design is considered to be the same level of evi-
dence as a randomised control trial. The authors have
designed the study with periods of non-treatment to re-
duce a wash-out effect of intervention. The results of
this trial were reported in two separate papers, one
examining the results after the first eight weeks of the
trial (after the initial ‘no intervention’period, one treat-
ment period, and one post ‘intervention no treatment’
period), with another reporting the results after the first
twelve weeks of this trial (inclusive of the initial ‘no
intervention’period, two ‘intervention’periods and the
‘no intervention’period between the two ‘intervention’
periods). The outcome measures included pain and ac-
tivity. The outcome of pain was measured with the
Borg’s CR-10 scale during two different sporting activ-
ities (A = most painful activity, B = less painful activity),
and the Engstrom activity index was utilised to measure
the participant’s physical activity intensity. The authors
reported lower levels of pain with the two self-selected
activities for the orthoses compared to the heel raises
(activity A odds ratio (95% CI): 0.22 (0.15, 0.34), p <
0.001, activity B: 0.18 (0.12, 0.27), p < .001). This study
was classified as providing Level 2 comparative efficacy
evidence supporting the use of orthoses compared to
heel raise treatments.
The second randomised control trial [40] was a pro-
spective intervention design with a sample size of 45
participants. This trial examined the use of orthoses over
a 4 week period compared to a ‘no treatment’control
group with outcomes measured at the beginning and
end of the four week ‘intervention’period. The interven-
tion referred to as a heel cup with a brim, though the
picture of these orthoses included in this manuscript
also indicated some medial arch support. The construct
of pain was captured in this trial through self-reported
pain experienced while participating in a chosen ball
sport, measured using the Borg CR-10 scale. The au-
thors of this paper reported that there was a significant
reduction in pain in sporting activities in the treatment
group in this study, however it was not stated which
statistical analysis method was used, no confidence inter-
vals or p-values were reported, nor which assessments
were being compared in making this statement. Instead,
the only data presented was the median values for each
group with (for intervention group only) and without
(for all participants) orthoses at the pre- and post-
intervention period assessments. Use of the orthoses
reduced pain with sport at the post intervention assess-
ment to median = 0.5 out of 10 compared to 5 out of 10
for the control group. Physical activity levels were
maintained in both groups.
These two randomised trials [38-40] were the highest
available evidence reporting the effect of treatment of
pain and maintenance of physical activity associated with
calcaneal apophysitis. There were a number of areas of
uncertainty regarding the methodology of these studies
as the study protocol and trial registration status was
unable to be obtained. Publishing protocols and register-
ing clinical trials ensures that the research is conducted
as required (CONSORT) [48] and that the statistical
analysis is transparent [49]. While the cross over design
of the first trial incorporated breaks between interven-
tions, given calcaneal apophysitis is a self limiting condi-
tion, there is still the possibility that there was a
continued wash out effect that carried through the inter-
vention groups. The randomised trials [38-40] as
reported, have statistical analysis concerns that limit the
validity of the results reported. The completed interim
analysis of both Perhamre 2011a and 2011c [38,40],
increased the risk of a type 1 error [50]. The final
randomised trial [39] also had areas of statistical concern
as no information regarding which statistical test used
was given and there was no indication of the precision
of the estimate provided.
Heel lifts
The use of heel lifts was reported in many of the studies
[17,38,39,41,44]. All of the studies reported that heel lifts
decreased pain, though many of them used these
concurrently with other treatment modalities such as
stretching and ice [17,41,44] and were unable to provide
results regarding the heel raises’efficacy alone.
The randomised trial previously mentioned [39] exam-
ined the use of heel raises within the group results of
the crossover randomised trial. The heel raise used
within this study was a 5 mm cork wedge covered with a
thin elastic surface, and was reported to lift the heel
5 mm in mid stance and push off. The design of this
trial permitted participant comparison of pain reported
when using no intervention compared to pain reported
when using the heel raises. Results for this comparison
indicated that pain levels were higher when using no
intervention compared to when using the heel raises.
Odds ratios (95% CI) for activity A of 2.32 (1.69, 3.19),
p-value < .001 and for activity B of 2.29 (1.67, 3.16),
p < .001 were reported where use of the heel raise was
the reference value. This data was classified as providing
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Level 2 evidence of efficacy of heel raises for reducing
pain with activity over no treatment, however the finding
arose from a pre-post within-group comparison, these
results should be viewed with caution.
Concurrently applied therapies
Many authors also incorporated strategies to both minim-
ise inflammation i.e. icing and active rest, together with
the minimisation of the proposed biomechanical contrib-
uting factors i.e. gastrocnemius and soleus static stretch as
standard, usual care treatments. No studies were identified
that examined these modalities as isolated treatment
entities. It is not known whether concurrent application
of these treatment approaches when investigating other
treatment modalities introduces treatment effect-diluting
or moderating (interaction) effects.
Discussion
This review has identified that there has been little
methodologically rigorous evidence generated to support
treatment options for calcaneal apophysitis. The avail-
able evidence indicated orthoses with a brim (heel cup)
and medial arch support was more effective in reducing
pain in sporting activities (Level 2 evidence) compared
to heel raises or no treatment. There was also support
for heel raises reducing pain in sporting activities (Level
2 evidence) compared to no treatment. Taping also
appeared to have some immediate pain relief benefit
(Level 3 evidence). Meta analysis was not undertaken
due to the variability of data collected during this review,
therefore our conclusions have been based upon a crit-
ical, narrative synthesis.
The findings of this review might be able to help
shed light over the causative mechanism of calcaneal
apophysitis. It is widely accepted that calcaneal apophysitis
is a self-limiting condition related to physiological changes
at the calcaneal apophysis as children transition to adoles-
cence. Given the causative mechanisms of calcaneal
apophysitis are still unknown, it was not surprising to find
a variety of treatment approaches advocated within the lit-
erature [15]. The treatment options reported within the
literature and their success may be based on a number of
theories of causative factors. Many researchers and clini-
cians continue to support the same baseline interventions
such as ice and restriction of sports. The effectiveness of
additional treatment options such as taping, heel lifts and
orthotics may be based on the supposition [51] that calca-
neal apophysitis is the result of either an increased trac-
tional pull at the calcaneal apophysis or from increased
impact forces at the plantar surface of the heel.
One causative factor of increased tension or shortness
of the achilles tendon may be due to the rapid growth
in adolescents. This soft tissue change may have the
potential to place an interim strain or traction on the
apophysis at the insertion [8,42], thus a simple heel raise
has been advocated to reduce this strain when footwear
is worn [17,38,39,41,44]. Similarly, there may be in-
creased tension or shearing force at the insertion of the
achilles tendon due to abnormal biomechanics at the
foot and ankle. During gait, the gastrocnemius and so-
leus muscles provide a plantarflexion mechanism at the
ankle while eccentrically contracting at midstance,
exerting forces on the subtalar joint [51,52]. If there are
abnormal forces going through the foot, the provision of
a heel raise may reduce the load in the achilles tendon
[53] or an inverted type of orthotic device has the poten-
tial to reduce the supination moment [54] and limit pro-
nation; both items reducing the tractional pull at the
achilles tendon calcaneal junction. A combination of
these theories may also be plausible.
It is not known exactly how calcaneal apophysitis de-
velops and if there is biomechanical abnormalities within
the foot that results in active children having heel pain.
The resultant success in pain relief an orthotic device
may come into play when used on a foot with an abnor-
mal windlass mechanism. The windlass mechanism is
the theory that describes how the plantar fascia and
achilles tendon interact during gait for propulsion. The
plantar fascia (windlass) is like a rope or cable attached
to the distal and inferior aspect of the calcaneus and the
proximal and inferior aspect of the metatarsophalangeal
joints. During the propulsion phase of the gait cycle, the
windlass activates and shortens the plantar fascia at the
metatarsals, therefore shortening the distance between
the calcaneus and metatarsals. This in turn elevates the
medial longitudinal arch [55]. It is possible what in a
foot with calcaneal apophysitis, the rearfoot valgus pos-
ition may be impacting the windlass mechanism and
changing the force required at the achilles tendon for
normal gait. The use of an orthotic has demonstrated
ability to influence the rearfoot position [23,41] and
therefore may positively impacts the windlass mechan-
ism; this in turn may reduce the loading required at the
achilles tendon for normal and pain free gait in the
symptomatic child.
Impact forces or increased plantar pressures at the cal-
caneal area may cause repetitive impact forces during
heel strike, further traumatising the apophysis [8,56]. If
this is also a contributing cause of the apophysitis, then
the use of an orthotic with a heel cup may centre the
calcaneal soft tissues (fibro fatty padding), increasing the
cushioning in this area and resulting in pain relief [40].
Likewise, a heel raise is often manufactured from material
with shock absorbing properties, again providing some
form of cushioning at the plantar surface of the heel.
No studies identified in this review examined the use
of ‘off the shelf’or prefabricated orthotics which have
also been known to reduce foot pain in adults with
James et al. Journal of Foot and Ankle Research 2013, 6:16 Page 9 of 11
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plantar fasciitis [57]. There have been no studies investi-
gating the use of prefabricated orthotic devices in neuro-
logically normal children with foot pain and it was
surprising these were not utilised within the studies con-
sidering the increased availability to health practitioners
and their relative low cost compared to custom made
orthotics.
It also appears from the literature that children who
play competitive sport were more likely to experience
calcaneal apophysitis [41,45,58,59]. This is a sub-section
of the general population, therefore extrapolation of the
treatment approaches and effectiveness demonstrated
within these studies to children who participate in nor-
mal sporting activities levels may not be appropriate.
While orthoses [38-40] were more effective in pain re-
duction during participant-identified activities compared
to heel raises, this may be due to the high impact on the
apophysis of many hours of training or an early sporting
injury due to abnormal biomechanics and strain. In the
child who plays normal school sports or minimal sport
after school, the use of a heel lift may be just as effective
in pain relief.
Overall, the treatment options reported, both work on
similar principles, however the level of effectiveness may
actually be based on the original cause of the pain. A
regular foot posture and normal foot biomechanics may
only require a heel lift to relieve pain, yet the child who
has additional foot posture changes may require some
type of orthotic with or without a heel lift to improve
foot function. Additional domains need to be explored
to better understand efficacy of treatment options, in-
cluding: establishing the level of sport played by children
who demonstrate this pain, determination of any ankle
equinus and understanding if there is a particular foot
type that is more receptive to one treatment over
another.
Conclusion
Calcaneal apophysitis is a condition that may present in
children and a cause of primary health care presenta-
tions. There has been limited high quality evidence iden-
tified to guide treatment approaches. While it appears
from the evidence that the use of orthoses and heel lifts
give effective pain relief; the studies promoting either
treatment modality have many study design concerns.
Primary care practitioners should exercise caution when
heeding this result. A randomised control trial incorpor-
ating short and long-term effects of appropriate treat-
ment modalities is indicated and a study design for this
has been published [60]. This research will strengthen
the evidence of effectiveness in the reduction of pain
and the maintenance of activity in children who present
with calcaneal apophysitis.
Competing interest
The authors declare that they have no competing interests.
Authors’contributions
All authors (AMJ, CW, TPH) contributed to the conception and design of this
systematic review. AMJ and CMW completed the systematic review and
scoring of the selected articles. All authors have contributed to the analysis
and have read and approved the final manuscript.
Author details
1
Podiatry, Peninsula Health Service, Melbourne, Australia.
2
Allied Health
Research Unit, Southern Health, Melbourne, Australia.
3
Monash University,
Melbourne, Australia.
Received: 15 January 2013 Accepted: 18 April 2013
Published: 3 May 2013
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doi:10.1186/1757-1146-6-16
Cite this article as: James et al.:“Effectiveness of interventions in
reducing pain and maintaining physical activity in children and
adolescents with calcaneal apophysitis (Sever’s disease): a systematic
review”.Journal of Foot and Ankle Research 2013 6:16.
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