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Sever’s Injury

A Clinical Diagnosis

Stefan Perhamre Centre of Sports Medicine, Värmland County Council, Karlstad, Sweden.

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Dagmara Lazowska Department of Radiology, Central Hospital, Värmland County Council, Karlstad, Sweden.

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Sofia Papageorgiou Department of Radiology, Central Hospital, Värmland County Council, Karlstad, Sweden.

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Fredrik Lundin Centre for Clinical Research, Värmland County Council, Karlstad, Sweden.

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Maria Klässbo Centre for Clinical Research, Värmland County Council, Karlstad, Sweden.

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Rolf Norlin Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.

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Background:

The diagnosis of Sever’s injury (apophysitis calcanei) has previously been partly based on radiographic findings in the calcaneal apophysis. Sclerosis and fragmentation have been supposed to represent signs of inflammation due to tractions from the Achilles tendon. The clinical findings, diagnostic criteria, and studied population are often poorly defined. We sought to define diagnostic criteria by analyzing clinical and radiographic characteristics in a population with Sever’s injury and to compare the findings with those of a control group of matched, symptom-free children.

Methods:

We assessed 30 consecutive children with Sever’s injury with high levels of pain but high physical activity levels in sports activities and 15 pain-free matched controls.

Results:

One-leg heel standing showed 100% sensitivity; the squeeze test, 97%; and the palpation test, 80%. All three tests showed 100% specificity. All of the patients and controls showed increased density of the apophysis. Half of the pain-free controls showed fragmentation versus almost 90% of children with heel pain.

Conclusions:

The diagnosis of Sever’s injury is clinical, not radiologic. Radiologic findings of increased density and fragmentation are found also in pain-free controls with high levels of physical activity and may, therefore, represent normal growth and development. We suggest that the diagnosis of Sever’s injury should be based on patient history and the results of two specific clinical tests. (J Am Podiatr Med Assoc 103(5): 361–368, 2013)

Corresponding author: Rolf Norlin, MD, Department of Orthopaedics, Örebro University Hospital, 70185 Örebro, Sweden. (E-mail: rolf.norlin@gmail.com)