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I have recently had a seemingly obvious Severs case turn into something quite a bit more than that. After the initial consultation 7 weeks ago, the patients mother called this morning to let me know what's been going on and to ask for my advice.
S) 12 year old girl with right heel pain 1 month duration.
P) Issued with gastrocnemius and soleus stretches.
Telephone conversation today reveals that severe pain developed a week after seeing me and starting the stretches, at the back of the leg from the heel to the knee. It became so intense that the patient got crutches and has been using them out of necessity for 5 weeks now. There is severe hypersensitivity to touch around the heel region (can tolerate touch along the calf / achilles), and wearing shoes and weightbearing is not possible because of this hypersensitivity. Some relief is gained by keeping the foot elevated. Upon questioning, the skin is pale in appearance (assuming due to foot being elevated much of the time) and there are no other skin colour changes or sweating noticed.
Radiographs, ultrasound and bone scans performed 4 weeks ago were all negative - no hotspot on bone scan at all.
Interestingly, she fractured the right patella 10 months ago: non-traumatic.
It seems much more than severs or achilles tendinopathy / calf muscle tear. I'm coming up with fibromyalgia. No other areas of pain or sensitivity though. Her Doctor has up until now asked her to give it rest and time, though she does have another appointment this afternoon.
Any other thoughts or lines of enquiry? Thanks for your help!
Rambling thoughts here.....I'm just wondering why she took so long to call if the pain response was that intense, did you ask?
I'd also be keen to know about the limited ankle joint dorsiflexion, how limited is limited? Is there the possibility that she has something underlying going on which has created muscle pain by overstretching? Is it also possible that when she stretched she overdid it and being a kid, it hurt and she didn't know how to respond to that pain?
Sometimes kids (even 12 year olds) just don't know how to express pain, especially if this is the first time they have ever experienced pain. If there was limited range then is it possible that the inflammation was increased with the stretching? Was she a toe walker, does she have CP? Some of the worst kids with sever's I've had is those with really mild CP.
As an aside, with the stretches, I only get the kids to stretch to the point until just before they feel pain or get them to avoid it until they they are able to stretch with minimal pain.
I'd also ask if they used any topical or oral antiinflamatory as they may have used something like nurofen and it masked the amount of pain and she overdid it.
I'd be less likely to consider fibromyalgia as it is rarely isolated to one area. I would be also interested to hear how much attention she is getting within given all the tests have come back clear.
Next option, MRI OR/AND some tough love.
Cylie.... in a permanent state of confusion
I'd be considering complex regional pain syndrome (CRPS).
This is rare-ish, but I've seen a handful of cases in 40 years of practice, so it does exist.
The condition can develop fairly rapidly, is characterized by extreme pain, and is accompanied by swelling, which in the cases I've seen developed after the pain - in this case probably the ankle and foot will be swollen. The skin turns mottled along the way. If this is what is developing I would refer straight on to a Rheumatologist.
I have just spoken to the child's mother. The GP has referred for MRI and to a sports physician.
In regard to the measurement of lunge angles, I take the angular measure from the anterior tibia. The paper above uses the achilles tendon for placement of the angle-finder. Can anyone tell me if I'm doing it wrong or are there advantages over the other method?
Have you considered pain referral from gastrosoleus? In the absence of any imaging evidence I suggest it is worth considering this.
Palpation might reveal tender spots in the calf area, but not necessarily in my experience. I you find tender spots, then myofascial release may help. Sometimes performing positional release while holding the sore area can be successful. If manual techniques don't appear to work, then a massage machine or acupuncture might work, followed by PNF stretches.
If you don't find tender spots, you may find tight strands within the muscles. Whether you find such evidence or not, I suggest it is worth attempting machine massage or acupuncture followed by PNF stretches.
I would be also interested to hear how much attention she is getting within given all the tests have come back clear.
Next option, MRI OR/AND some tough love.
Whilst I've seen the odd Sever's requiring crutches - usually with outside norm mechanical characterisitics, I agree with Bug (and I am by no means of the same calibre!). Occasionally I've seen a young-un that gets "doted" on perhaps milking the sympathy a bit. Though 12 is getting abit older IMO.
Was the mother answering all the questions on the initial consultation? How was the interplay between 12yo and mother? DOes the child have any siblings going through a busy time etc. etc. Just my thoughts anyway,
Last edited by björn : 8th May 2012 at 04:10 AM.
I was wondering while you were on the topic of Severs someone could throw me some advice (I've only seen a handful of these cases- have only been out for uni for 1.5years).
Patient: 11 year old girl with heel pain. GP thought it may be plantar fasciitis and have gel heel cups which did not work. Patient came into clinic, bilateral heel pain worsens with running and sport. Tight gastroc-soleal complex. Pes planus, excess pronatory phase and functional hallux limitus.
Tx: I gave calf stretches and low dye taped. On review, taping had taken pain away whilst on. Stretches were also helping but pain still there. Gave pre-fabs (3/4 ICB) and explained wearing in and to continue stretches. On review patient found the arch of orthotics felt too hard, so I lightly grinded this area which patient said improved area. Next review patient found they were not working, they had worn them for one hour and found they were too much under the arch. I explained it was normal to feel strange at the start. The Mother was angry at the child for not following the wearing in program. We have now started the wearing in 3 times and the child is not progressing past first day. My next thought is adding a heel lift but the child has been doing se well with the stretches..
Can I ask where on the heel is the pain and is there pain on palpation?
What is the pt footwear like?
What is the FPI?
I have found patients in maximal sub-talar joint pronation (in relaxed stance) can find orthoses with a firm built up medial arch too much in their MLA, I usually use temporary orthoses like a slimflex with a rear foot varus post and EVA heel raise (with a 1st ray cut out if they have a FnHl). For a permanent device, chose something with a low arch profile in a firmer material (casted or something like a interpod flex 4 degree)
I would add a heel raise along with the stretches, and advise on the importance of stretching, I personally ask my pt to stretch while brushing their teeth in the morning and evening, as I am a big believer that if you can get pt to do stretches with out taking more time out of their day they are more likely to do them. Once the heel pain begins to reduce I slowly reduce the heel raise height over time until there is no heel raise. I usually explain as well that it is severs it usually a self limiting condition.