Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever's disease)?

Conservative Treatment of Sever's Disease: A Systematic Review

Background: Sever's disease, or calcaneal apophysitis, stands as the most prevalent cause of heel pain in children, often linked to sports like soccer, Australian football, and basketball. While various therapies are documented in the scientific literature, the standard choice is conservative treatment. Thus, the objective of this research was to assess the effectiveness of diverse conservative methods and techniques in alleviating Sever's disease symptoms. Methods: Systematic searches were conducted in October 2023 in PubMed, Web of Science, Scopus, SportDiscus, and PEDro, using terms like Osteochondritis, Osteochondrosis, Apophysitis, Sever's disease, Calcaneus, Adolescent, Child, and Childhood. The PEDro scale gauged methodological quality, and the Cochrane Risk of Bias tool evaluated the risk of bias. Results: Eight randomized controlled studies were included, featuring commonly used treatments such as insoles, therapeutic exercises, Kinesio taping, and foot orthoses. The methodological quality was generally good, with an average PEDro score of 6.75 points. Regarding bias, four articles had low risk, three had high risk, and one had some concern. Conclusions: Conservative treatment emerges as an effective option for alleviating symptoms associated with Sever's disease.

International differences and inaccuracies in the public advertising about calcaneal apophysitis: an audit of websites originating in Australia, UK and USA

BACKGROUND

Calcaneal apophysitis is a common condition in childhood. Parents often seek online information for children's' health care concerns prior to seeking care. Therefore, we aimed to evaluate the credibility, readability, and accuracy of calcaneal apophysitis advertising on popular websites in three countries.

METHODS

We used content analysis of publicly accessible data. This involved identifying the top 50 websites in each country from their hit rates. We used elements of validated tools to audit and determine frequencies relevant to credibility (e.g. publisher), readability (e.g. literacy score) and accuracy (e.g. alignment with evidence). Data were analysed quantitatively and reported against each element.

RESULTS

Websites were predominantly hosted by private health services (n = 118, 79%). The mean (SD) SMOG (readability) score was 9.3 (4.5). The majority of websites (n = 140, 93%) provided at least one treatment recommendation, and less than 10% (n = 11) of websites advertised treatments fully aligned with evidence. Use of treatment modalities without evidence and with high risk to children were also found including surgery, extracorporeal shock wave therapy and laser.

CONCLUSIONS

Calcaneal apophysitis online advertising is mostly curated by clinicians. Clinicians should consider revising online advertising to increase understandability and accuracy to reduce health care wastage, risk, and low value care.

Characteristics of Pressure on the Apophysis in the Course of Paediatric Heel Pain-Preliminary Report

Increased pressure on the heel apophysis is often implicated as a cause of paediatric heel pain. However, there are few reports on the causes of the increased pressure and its origin. Therefore, the aim of this study was to analyse the distribution of pressure on the feet in children with heel pain. The study included 33 paediatric patients with non-traumatic heel pain, i.e., 24 boys (73%) and 9 girls (27%), aged on average 11.2 years (±3 years). Pedobarographic diagnostics proved a decrease in the pressure on the heels in relation to the ground and the transfer of the projection of the centre of gravity to the forefoot. While standing, the average contribution of the pressure on the heel was 0.52, SD = 0.14 in children with normal and reduced weight. In overweight children, the average pressure on the heel was higher (0.60, SD = 0.08), but the small number of children with this characteristic (n = 4) did not allow conclusions to be drawn in this area. Heel underload was also demonstrated during gait. However, the assessment of this aspect requires additional observational analyses in the field of propulsion and gait phases. The reduced pressure on the heel promotes apophysis traction, causing intracanal compression. Studies have shown that the causes of apophysis traction may be postural defects (in particular, forward inclination of body posture) and overpronation of the foot, or defects in the metatarsal area.

Quantifying the ossification and fusion of the calcaneal apophysis using computed tomography

Knowledge of the anatomical development of the calcaneal apophysis is essential in clinical assessment and management of both paediatric and sub‐adult patients presenting with heel pain. Despite this, the current understanding of calcaneal apophyseal development is constrained by the limitations of the imaging modalities used to examine the apophysis, with no current literature reporting the development of the medial and lateral processes. This study aimed to overcome these limitations by investigating the ossification and fusion of the calcaneal apophysis using three‐dimensional computed tomography analysis, and statistically predicting the apophyseal developmental stage in contemporary Australian children. The development and fusion status of the apophysis was scored using a novel 11‐stage scoring system on 568 multi‐slice computed tomography scans (295 females; 274 males) and 266 lateral radiographic scans (119 females; 147 males) from the Queensland Children's Hospital. Multinomial logistic regression along with classification tables and predictive probabilities were then utilised to assess developmental stage likelihood from known age and sex. The apophysis commenced ossification at a mean age of 5.2 years for females and 7.2 years for males, and then elongated to form the apophyseal cap around 10 years for females and 12.4 years for males. Fusion of the apophysis commenced at a mean age of 11.18 years for females and 13.3 years for males, with the earliest age of complete fusion observed at 10 years for females and 14 years for males. The results demonstrate significant sexual dimorphism in ossification and fusion with females developing and fusing significantly earlier. Furthermore, the use of computed tomography in this study allowed for the first time evaluation of the ossification and fusion of the medial and lateral processes of the calcaneus. The medial process formed at a mean age of 9.5 years for females and 10.9 years for males while the lateral process formed at around 9.8 years for females and 11.7 years for males. The medial process demonstrated slower rates of fusion compared to the lateral process. The present study provides Queensland specific standards for assessing the calcaneal apophyseal developmental stage as well as novel predictive regression models for apophyseal stage estimation using known age and sex to aid in the diagnosis of heel pain conditions such as apophysitis or screen for developmental delays in children and subadults.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Sever's Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations

Sever's disease is an underreported prevalent pediatric condition that causes heel pain in children worldwide. It is often described as an overuse injury that can present with either unilateral or bilateral heel pain. Even though the exact mechanism of injury is unknown, it is often thought it involves repetitive stress and pressure on the calcaneal growth plate. Diagnosing Sever's disease mainly relies on a thorough clinical investigation and physical examination, with a positive squeeze test usually sufficient to establish diagnosis. Nevertheless, radiographic imaging can help exclude other differential diagnoses. Therapeutic options of Sever's disease are mostly conservative, and these include rest, physical therapy, kinesiotherapy, and orthoses. Educating parents and coaches on the symptomatology and presentation of Sever's disease is pivotal for the establishment of efficient preventive interventions and earlier diagnoses. This study presents a case of a pediatric patient with Sever's disease and offers medical insight into the diagnostic, clinical, pathologic, and therapeutic characteristics of this condition, in light of the current existing literature.

Radiographic study of Sever's disease

X-ray and MRI differences of calcaneal epiphysis between Sever's disease patients and normal children were compared and analyzed to raise awareness of Sever's disease. A total of 98 children with Sever's disease were enrolled in the study, including 72 males and 26 females. Among them, 6 patients underwent MRI. There were 120 patients in the control group, including 73 males and 47 females, aged 8 to 15 years. The calcaneus epiphysis density (compact and cancellous bone type), the difference of the radiolucent line and the signal changes of Sever's disease on MRI of the two groups were observed and analyzed. Among the patients with Sever's disease, the male incidence rate was 79.59%, the female incidence rate was 20.41%, the average age of onset was 11.35, the average age of onset for male was 11.49, and the average age of onset for female was 10.80. There were significant statistical differences between the two groups in terms of epiphysis density (compact and cancellous type) and translucent line (χ²=38.85, 137.51, P<0.05). Six cases of MRI showed partial or complete different degrees of bone marrow, ligament, soft tissue edema, and joint effusion. Sever's disease is mainly characterized by increased density of the calcaneus epiphysis and a radiolucent line of the epiphysis. It manifests as heel edema on MRI image.

Osteomyelitis complicating Sever's disease: A report of two cases

Sever's disease is a common cause of heel pain in young children and it has a self-limiting course without long term complications. Osteomyelitis of calcaneus is a sinister condition which can lead to serious complication if treatment is delayed. Indolent nature of calcaneus osteomyelitis leads to overlap in its clinical picture with Sever's disease. Two cases of Sever's disease which were later diagnosed and managed for osteomyelitis are reported. Salient differentiating features of Sever's disease and calcaneus osteomyelitis along with management strategy are discussed.