Calcaneal Apophysitis ( Sever ’ s Disease ) : MRI Findings

Calcaneal apophysitis (Sever’s disease), is the most frequent cause of the heel pain in growing children. The diagnosisis generally made with a typical history and clinical examination. Imaging modalities including radiography and magnetic resonance imaging can help establish the diagnosis. In this case we report imaging findings of an 11-year-old boy diagnosed as Sever’s disease. J Nepal Paediatr Soc 2015;35(2):172-174


Introduction
C alcaneal apophysi s (Sever's disease), is the most frequent cause of the heel pain in physically ac ve growing children 1,2,3,4,5 .The diagnosis of Sever's disease is generally made with the typical history of posterior heel pain that exacerbates with physical ac vity and clinical examina on fi ndings of no or mild swelling without any local skin manifesta ons like eryhtema or edema 1,2,3 .Although the requirement of using radiological methods for the diagnosis of Sever's disease is controversial, foot radiographs are used to be obtained as a part of the rou ne clinical evalua on 1,4,5 .Moreover, imaging methods could be useful in order to exclude other pathologies like fracture, tumors, and osteomyeli s 6 .However, radiography fi ndings of this disease may be also seen as a variant of normal 3,4 .Therefore, magne c resonance imaging (MRI) can play a crucial role in the diagnosis of relevant cases 6,7 .We herein report an 11-year-old boy diagnosed as Sever's disease with both radigraphy and MRI fi ndings.

The Case
An 11-year-old boy was admi ed to our hospital with the complaint of the right heel pain that exacerbates with the physical ac vity for the last two weeks.The pain ini ated spontaneously without any history of trauma.There were no associated complaints or history of chronic illness.Physical examina on was normal except tenderness of right heel.Laboratory tests were within normal limits as following; haemoglobin 13.8 g/dl, white cell count 5×10 3 /μl, platelet 300×10 3 /μl, erythrocyte sedimenta on rate 16 mm/hr, C reac ve protein 3.98 mg/dl.In the light of the clinical and laboratory fi ndings, Sever's disease was considered as a preliminary diagnosis due to presence of the isolated tenderness and heel pain on physical examina on without any history of trauma and chronic illness, and accompanying unremarkable laboratory fi ndings.Radiographs of the bilateral feet and magne c resonance imaging (MRI) of the right foot were obtained to exclude other pathologies causing heel pain.Radiographs revealed increased density and fragmenta on of calcaneal apophysis on both sides (Figure 1).MRI showed fi ndings of the right calcaneal apophysi s including; fragmenta on, which was be er seen on T1 weighted images, hyperintensity consistent with oedema on fat saturated T2 weighted images and enhancement following contrast administra on on fat saturated T1 images (Figure 2).
The radiographs and MRI were otherwise unremarkable.Therefore, the diagnosis of Sever's disease was established.He was recommended to restrict physical ac vi es and prescribed oral aninfl ammatory drugs.

Discussion
Sever's disease is thought to occur due to repe ve microtrauma caused by trac on on the adhesion site of the Achilles tendon to the calcaneal tuberosity 4,7 .This is the most frequent cause of the heel pain in children and the diagnosis is usually made with clinical history and physical examina on 1,2,3,4,5 .Pa ents o en suff er from chronic heel pain and approximately in 60% of the cases complaints are associated with both heels.The average age at presenta on is 11 years, ranging from 8 to 15 years.It is more commonly seen in boys with a 2-3:1, male:female ra o 2,4 .Diff eren al diagnosis list of the heel pain in a child may also include other condi ons like fracture, osteomyeli s, Achilles tendoni s, retrocalcaneal bursi s, calcaneal cysts, tumors, and plantar fascii s 5,7 .During the clinical evalua on, foot radiographs are generally obtained for excluding other pathologies 6 .Although fragmenta on and increased density of the calcaneal apophysis observed in radiographs are defi ned as radiographic fi ndings of Sever's disease, these fi ndings are not pathognomonic for the diagnosis and can be also seen in healthy children 1,2,4,5 .MRI is another useful imaging modality which can be implemented in exclusion of other causes of heel pain par cularly in doub ul cases 5,6,7 .Infl ammatory fi ndings like bone marrow edema and enhancement a er gadolinium administra on within the calcaneal apophysis can be detected with MRI 6 .An -infl ammatory medica ons and restric on of physical ac vity are the treatment of choice in such cases 4 .

Conclusion
In conclusion, Sever's disease should be kept in mind in physically ac ve growing children when the heel pain is present.In relevant cases implementa on of MRI may help to establish the diagnosis.

Fig 2 :
Fig 2: Fragmenta on of calcaneal apophysis was seen on sagi al T1 weighted image (a), hyperintensity consistent with bone marrow edema on axial fat saturated T2 image (b), enhancement a er contrast administra on on sagi al (c) and axial (d) fat saturated T1 images were also shown.

Fig 1 :
Fig 1: Radiographs revealed increased density and fragmenta on of calcaneal apophysis on both sides (arrows).