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Is Radiographic Evaluation Necessary in Children With a Clinical Diagnosis of Calcaneal Apophysitis (Sever Disease)?

Rachel, James N. MD; Williams, John Barton BA; Sawyer, Jeffrey R. MD; Warner, William C. MD; Kelly, Derek M. MD

Journal of Pediatric Orthopaedics: July/August 2011 - Volume 31 - Issue 5 - p 548–550
doi: 10.1097/BPO.0b013e318219905c

Background Calcaneal apophysitis (Sever disease) is most often diagnosed clinically, and radiographic evaluation is believed to be unnecessary by many physicians. To evaluate the need for radiographic evaluation in children with a clinical diagnosis of calcaneal apophysitis, we determined the frequency of abnormal radiographic findings in a group of patients with this clinical diagnosis.

Methods Clinical records and radiographs of all children between the age of 4 and 17 years who presented with a chief complaint of heel pain were retrospectively reviewed. Patients with an insidious onset of heel pain were included; those with acute trauma and a diagnosis of Achilles tendinitis were excluded. Radiographs were reviewed by 3 orthopaedists (blinded to the clinical diagnosis) to determine if any radiographic abnormalities were present. Clinical records were reviewed in an attempt to determine what factors, if any, indicated a diagnosis other than calcaneal apophysitis.

Results Review identified 98 patients (134 feet) with a mean age of 10.8 years who had a clinical diagnosis of calcaneal apophysitis. Positive radiographic findings (all on lateral radiographs) were identified in 5 patients (5 feet): 3 calcaneal unicameral bone cysts, 1 distal tibial nonossifying fibroma, and 2 calcaneal stress fractures (1 patient had both a calcaneal unicameral bone cysts and a stress fracture in the same foot). The rate of abnormal radiographic findings in the 96 patients was 5.1% (3.75% in the 133 feet).

Conclusions The abnormal radiographic findings seen in 5.1% of children usually led to more aggressive treatment including close radiographic follow-up or immobilization. No common findings in the history or examination indicated patients who were more likely to have positive radiographs. Despite concern about exposure to ionizing radiation and the cost of medical imaging, routine lateral radiographs appear to be justified for screening of pediatric patients with heel pain. If a diagnosis of calcaneal apophysitis is made without obtaining radiographs, a lesion requiring more aggressive treatment could be missed.

Level of Evidence Level IV, retrospective case study.

Le Bonheur Children's Hospital and the Department of Orthopaedic Surgery, University of Tennesee-Campbell Clinic, Memphis, TN

Supported by none.

Reprints: Derek M. Kelly, MD, 1211 Union Avenue, Suite 510, Memphis, TN 38104. Email:;

Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.