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Severs

Or pain on your heel as you might know it! 

This often occurs in the younger athletes, those between the ages of 7 and 10 years old but can still be present in those up to 13 years old as every grows and matures at different rates. 

It is the second most common of this type of injury and occurs mainly in sports which require lots of jumping and landing activities such as gymnastics, dancing, basketball and netball amongst others. 


So….

What type of injury is it? It is define as a Traction Apothesitis of the insertion of the achilles tendon to the calcaneus. 

A traction apothesitis is the inflammation and micro fracture to a soft area of bone where repeated micro trauma has caused the tendon to pull at the softer bone. When an adolescent is growing, the bony areas are the weak link in the system as they grow quicker than the muscles and tendons so tension is created over softer bone going through the growing stage. Then when we apply load through this in the form of sporting activity the repeated contraction and high tensile forces of an already stretched muscle / tendon system pulls at the immature growing bone.

It sounds worse than it is and although the term micro fracture is used, it is not a fracture in the sense you would normally think of it, but more part of the normal growing process. 

In Severs, this is the repeated contraction of the calf complex which may cause some softening and / partial avulsion (pulling away) of the tendon over the ossification (bony growth) centre. 

How do we know it’s Severs? 

Diagnosis is clinical in that we don’t in the initial stages need scans. A good physiotherapist or sport medicine doctor will be able to tell you what it is from talking to you about the symptoms and examining you. Common symptoms include quite pinpoint pain over the achilles and heel bone; swelling and tenderness in the same location (insertion of the achilles tendon), or you may describe a lump; pain during exercise in particular running and jumping; pain on direct contact i.e. it may be difficult to wear certain types of shoes and they will run and irritate; going up onto tip toes, landing and squatting down may be painful. 

The liklihood is there may have been a growth spurt around the time or in the previous couple of months (but not always), and actually in around 60% of cases it can occur on both heels. 

How do we get it better?

You hear a lot of people talk about this as growing pains and that you will grow out of it. Essentially this is true, the pain will settle at the time of the bony fusion of the calcaneus….when that soft bone becomes hard. However this may be 6-12 months and there is no saying that it might not happen again at another growth spurt. So there are things that can be done. 

  1. It is a self limiting condition! Therefore it is important that we apply some activity modification

The last thing we want to do is stop you doing what you enjoy, and at the elite level this can be even harder. However, the more you train and compete the worse the pain will get. Therefore there needs to be a degree of prioritising. For example, can you reduce the other sports and activities you do to focus on your main sport? Can you reduce the time or intensity of your sessions? Can you miss one training session a week or do something in its place that doesn’t cause the pain? These are the questions you need to be asking and planning with your coaches, parents and physio.

One of attempting this might be similar to the below, but always talk it through with people: 

  • Pain during training only = approx. 25% reduction in global Physical activity 
  • Pain during training and after (few hours) = 50% reduction in global physical activity 
  • Pain during training and after (following days) impact on daily life = 100% reduction in global physical activity 
  • Pain during training and after with impact on daily life at different sites = 100% global reduction in physical activity + sports diversification for 1 year 
  1. Ice

Ice can provide an analgesic effect (pain relief) therefore it is a good thing to help you recover after a training session, competition or you rehabilitation. (It won’t fix you but will help manage the pain). 

  1. Heel Raise 

Similar to the ice, inserting a heel raise into you shoe might help reduce some of the pain for a short period whilst you do your rehab. 

  1. To Stretch Or Not To Stretch 

Stretching is the contentious topic when it comes to Severs and other Traction Apothesitis injuries such as Osgood Schlatter. Tendons attach muscle to bone. Therefore in theory if we were to stretch a muscle which is already under tension from the bone growth then that stretch is going to pull the tendon which is then going to pull at the soft bone more….at worst making it worse and at best not allowing us to recover. However we do need to get back to stretching at some point as the tissue will need to be able to tolerate all the movements again. So current advice is: 

  • If you have a acute pain i.e. it is really sore for a large majority of the time then don’t stretch 
  • If it is sore to stretch then don’t stretch 
  • If you can stretch and you get no pain on stretching then stretch as much as you like 
  1. STRENGTHENING 

I put this in capitals as this, above all the other points the the most important thing you can do to help. When we think of rehab it is important to think about the need to improve the capacity of the tissue; increase strength then attempt to apply this increase in force potential under progressively time constrained movements skills specific to sport. This will build your tolerance to be able to do your sport again, given you more time before pain kicks in. Also, the good thing about strength work is that we can strengthen to lengthen. So applying load, particularly the eccentric contraction or the downward phase of an exercise can help lengthen tissue better than stretching can. 

A typical rehabilitation programme would follow the below. You can pitch in at whatever stage you feel appropriate, i.e. if yo can do double leg calf raises 3×25 with no pain, then you need to move on to single leg calf raises. 

**DISCLAIMER** This is purely meant as a guide and does not replace consultation with a qualified professional. All exercises are performed at an individuals own risk

Phase 1

  1. Plantar flexion with theraband 
  2. Isometric (static) calf raise double leg
  3. Isometric (static) calf raise single leg 
  4. Double leg calf raise from floor (3×25 is the goal)
  5. Single leg calf raise from floor (3×25 is the goal)

If all fine and pain free move to Phase 2

Phase 2

  1. Single leg calf raises off a step straight leg (3×25 is the goal)
  2. Single leg calf raises off a step bent leg (3×25 is the goal)
  3. Weighted Single leg calf raises off a step straight leg (3×8-12 and increase weight)
  4. Weighted Single leg calf raises off a step straight leg (3×8-12 and increase weight)

If all fine and pain free move to Phase 3

Phase 3

  1. Increase weight on calf raises 
  2. Squat 
  3. Lunge 
  4. Step and land 

If all fine and pain free move to Phase 4

Phase 4

  1. Keep increasing weight on calf raise until reps are 3×6
  2. Jumps for time and then hops for time (3×30-60 secs)
  3. Jumps for height and then hops for height (3×6)
  4. Multidirectional hops 
  5. Have some fun (1, 2) / Sport specific rehab!!!

Phase 5 

Graded return to training / back to the things that were hurting 

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