Distal calcaneal apophyseal fracture in young athletes: two cases report

Miguel Pereira Filho, MD

Mauro Dinato, MD

Marcio Freitas, MD

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I have no potential conflicts with

this presentation.

Introduction

• Sever apophysitis is a major cause of foot pain in children.

• Typically affects young athletes who perform activities related to running and jumping, such as football and gymnastics.

Introduction

• Benign course, in general

• Treatment: stretching, rest and modification of physical activities

• Resolution of the symptoms in a period of two weeks to two months

Introduction

• Nowadays, the young athletes practices vigorous physical exercises leading to appearance of complications

• We will report 2 cases of gymnasts with Sever disease that developed avulsion of the distal epiphysis through the plantar fascia

Case 1 • Female, 15 years old, heel pain for months

• Worsening of symptoms after intensifying exercises

• She was diagnosed with Sever, used immobilizing brace for 6 weeks, 4 of them non weight bearing

• Gradually returned to training without symptoms.

Case 1 • 11 months later, when starting to

jump she felt pain at the site of her previous injury.

• Avulsion of the distal portion of the epiphysis was diagnosed.

• She was treated surgically, with resection of the fragment.

• 4 weeks later, returned to full activities.

• 6 weeks after surgery, she was competing on the uneven bars.

Case 2

• 15 years old boy, which presented severe pain in the plantar region of the right foot after jump.

• Three months earlier, he was already presenting pain, which had been worsening after workouts.

• No treatment or change in their physical activity was instituted until the worsening of symptoms

• The X ray showed avulsion of the distal portion of the calcaneal apophysis with plantar and medial deviation.

• The treatment consisted on resection of the fragment.

• He returned to training in 12 weeks.

Discussion • Sever's disease was first described in

1912 and used to affect overweight and physically active children and adolescents

• With the increasing frequency and intensity of exercises, the apophysitis is now also reaching athletes and non-obese children.

• Sports that involve running and jumping have increased incidence of the disease, soccer in particular

• Recently, some authors described avulsion injuries of the epiphysis in patients with Sever.

• Almost all injuries described occurred in the proximal portion of the epiphysis (avulsion through the Achilles tendon).

Imai Y, et al Calcaneal apophyseal avulsion fracture. Arch Orthop Trauma Surg. 2007 Jul;127(5):331-3.

Discussion

• Studies using magnetic resonance imaging showed the presence of bone edema and hemorrhage in the metaphyseal bone, near the epiphysis in children suffering from Sever.

• After treatment, these changes disappeared.

• The author concludes that a stress fracture occurs near the epiphysis, and the treatment should be more careful, including non-weight bearing immobilization.

Discussion

• The 2 cases described here, as well as others in the literature, demonstrate that patients with Sever can develop more serious injuries.

• This risk group is formed by individuals who do intense physical activities, in particular in 2 sports: soccer and gymnastics.

• We suggest that, in patients who are at higher risk of complications, a more careful treatment must be instituted, avoiding early return to sports

References • www.aofas.org

• www.cob.org.br

• Adirim TA, Cheng TL.. Overview of injuries in the young athlete. Sports Med. 2003;33(1):75-81.

• Cassas KJ, Cassettari-Wayhs A. Childhood and adolescent sports-related overuse injuries.Am Fam Physician. 2006 Mar 15;73(6):1014-22.

• Ogden JA, Ganey TM, Hill JD, Jaakkola JI. Sever's injury: a stress fracture of the immature calcaneal metaphysis. J Pediatr Orthop. 2004 Sep Oct;24(5):488-92

• Micheli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. J Pediatr Orthop. 1987 Jan-Feb;7(1):34-8.

• Sever, JW: Apophysitis of the os calcis. NY State J Med. 95:1025 – 1029, 1912.

• Madden, CC; Mellion, MB: Sever’s disease and other causes of heel pain in adolescents. Am Fam Physician. 54:1995 – 2000, 1996.

• Imai Y, Kitano T, Nakagawa K, Takaoka K. Calcaneal apophyseal avulsion fracture. Arch Orthop Trauma Surg. 2007 Jul;127(5):331-3.

• Lee KT, Young KW, Park YU, Park SY, Kim KC. Neglected Sever's disease as a cause of calcaneal apophyseal avulsion fracture: case report. Foot Ankle Int. 2010 Aug;31(8):725-8.