KIDS and PAIN: Part 2: Sever’s syndrome and ankle issues.
I am going to put the exact introduction and lead in that was used in Postural Development and Pain Reduction for children and Youth : why we are doing it wrong. Part 1: Knees
There is no doubt in my mind that everybody is noticing the change/transition that is happening with children and the youth of today. We can obviously come from many different angles with regards to that statement but I will stick with the main attraction and why I will be busy for years to come. POSTURE and PAIN. The quantity of children and young athletes seeing practitioners with increased and constant knee pain and instability, foot and ankle pain and instability, Osgood Schlatter syndrome, Sever’s disease (calcaneal apophysitis) and even hip and back pain has increased immensely.
As an Exercise Physiologist that has worked with improving biomechanical integrity and reducing pain associated with growth issues and excessive training load with many young athletes I have noticed a certain trend with this increase of pain and postural issues. I would love for you to be standing in front of me so I could paint you a great word picture but instead I will do my best through text.
TENSION and PAIN associated with insertion points: there is one common theme between the two syndromes or diseases stated above (Osgood Schlatter and Sever’s) and that is the basis of them being insertion points for muscles or muscle groups. This time I am focusing on Sever’s Sydnrome
Sever’s Sydnrome/Disease is a common cause of heel pain in active children. It is also called calcaneal apophysitis occurs when the growth plate of the heel is injured or chronically inflamed by excessive forces and loads during early adolescence. It is known to occur during growth spurts of adolescence usually between the ages of 8-13. Like Osgood Schlatter’s this is an insertion point, but this time it is for the Achilles tendon which is the tendinous end point for the gastrocs and the soleus (also known as the calf). As you can imagine, the amount of pressure and load through the calves of any active child is immense to say the least and when you include a possible growth spurt into the mix, it can be quite a painful experience for your children.
So how do we fix this?
UNDERSTANDING THE CAUSE: Why would children nowadays be suffering such an issue much more than before? Well I am going to present my case and what I use personally use to assist the kids that come in with this issue and you can make your own mind up based on my reasons and justification. I will say that it’s not based on some text book that tells me what to do based on some outdated research. With any chronic inflammatory condition (not caused from an impact or immediate injury), it has taken a decent period of time for tension to rise to a point where the individual feels pain or it is evidently swollen. There is nothing more beneficial than educating and empowering the individual the control their own pain and discomfort, in conjunction with the fact that everyday reminders to your body to reduce tension and increase range of motion are more beneficial than the once per week visit to a practitioner (and much less expensive too).
The first thing I want you to do is look at a baby and watch the way they squat down to pick something up; you may notice that they have a nice straight back, their hip, knee and ankle creases are all at full range of motion and their feet are flat with their heels flat on the ground. This final part (heels FLAT on the ground) is one of the major factors if not the most important indicative factor in this issue. As I have mentioned before, the tension and load of muscles will get sent to the end point which in this case happens to be the insertion point of the Achilles tendon. As muscles get used excessively they become tighter and in many cases will reduce in length due to constant contraction with minimal lengthening work as part of a program (either called flexibility or mobility training). In conjunction with this, we often become lazy and move differently (for example picking things up off the floor by bending at the hips and keeping the legs almost straight instead of like the squatting baby) which in turn reduces the length relationship of muscles. In the case of the full squat or “baby squat” the major influence is calf length which you may have noticed when you tested your child that they couldn’t sit like a squatting baby with their heels flat instead their feels rose off the floor. This excessive tension coupled with the growth phase of your child can cause major pain at this insertion point, also known as Sever’s disease.
Shoes are a huge factor in the “natural” increased tension of the posterior muscular chain (calves, hamstrings, glutes, lower back and spinal extensors): nowadays shoes are so built up to “protect” the foot that they don’t even let the foot do what it needs to do; and that is feel the ground, adjust appropriately to different surfaces and angles whilst providing the body with a stable basis of support to adjust accordingly when moving. The influence of this shoe heavily reduces the ability of the child’s foot to learn what its job is in life. Instead it relies on the locked and restricted aspects of the shoe and does not neurologically and physically develop as it should. You can read more about my view on shoes and which ones might be best for you HERE. The major issue with these style of shoes with regards to Sever’s is that they prop you up onto your toes due to a slightly or highly elevated heel. You may be asking what’s wrong with this? By propping you up from the heel in the shoe, your body automatically adjusts its centre of mass forwards. Automatically this makes your posterior muscular chain (elaborated on above) work constantly. It may be subtle but in many cases (from experience) this is enough to cause a chronic pain and discomfort from a build-up of tension. To the body this is like standing on your toes constantly (well for as long as you have been standing, running, or walking for).
HOW TO FIX THIS: a combination of conservative therapy and active therapy (dependent on severity of pain and phase of issue) including:
ice for immediate pain relief and reducing inflammation
natural topical anti-inflammatory (arnica, melaleuca, hypericum or my personal favorite Fisiocream which has all of these one place)
specific muscle tension relief through foam rolling or trigger point/muscle release balls, personal active release techniques (or use a tennis ball or lacrosse ball to save money),
Specific mobility techniques (taught by a practitioner) to increase posterior chain length, reduce constant tension and reduce translation of centre of mass.
If necessary some kinesio or rock tape to assist
Reducing the negative influence of shoes on your child’s development.
LONG TERM STRENGTHENING AND CHANGES: I will use my last blurb from this section because it works perfectly. The body is an incredible unit of many pulleys and levers that influence above and below the actual cause of an injury. In other words that headache you might get is not usually caused by you sore neck and shoulders, it is caused by your chest muscles pulling your shoulders forward that influences your shoulder position and shoulder blade (scapula) positioning which therefore moves your head forward (every centimetre your head moves forward is between 6-10kgs of extra load to your muscles) to compensate for this displacement which loads up your neck muscle and mal-aligns the cervical spine which causes a neurological/muscular painful response such as a headache. Simple to understand right?
SPECIFIC LINKS: to control and reduce knee tension and loading through insertion points will be individualised dependent on sex, age, activity and many other factors but just so you can appreciate the intricacy of the human body; I have listed some below
Improve ability to get back into a baby squat again comfortably. A very basic way to do this is sit down to a low step without using your hands, lean back until your back is straight and then use momentum to stand back. Perform this 20 times morning and night for two weeks and see how much your range of motion has improved. Ensure all the weight is situated on the heels with your knees facing outwards when you sit down. If you have specific knee pain please consult your practitioner before undertaking this activity.
Specific foam rolling or active release techniques for the gastrocs and soleus. Ensure you focus on the lateral, middle and medial aspects of each section you choose to work on. Feel free to find a Youtube video on how to do this or consult a practitioner on how to perform this.
Ensure you have the right shoes for your child. The younger they are, the better their ability to improve very quickly as well as absorb neuromuscular information to benefit their movements. If they are playing in a park; get them to take their shoes off so their muscle, bones and tendons can benefit like they should be without the restriction of the shoe.
Ensuring utmost range of motion and joint integrity throughout all movements necessary in life (squatting like a baby, lunging etc)
Get your child to focus on putting more of their weight onto their heels when they are standing. If you notice their shoes simply do not allow this to happen. Possibly consider getting them different shoes.
So that is just Sever’s syndrome for today. Whether your child is running, jumping, sprinting, squatting, hiding, seeking or doing any form of activity that involves their entire body especially loading through the legs and calf muscles then the information explained above will be really important to them in the coming years as they grow. If you would like some more information or a specific assessment of your child, children or even yourself if you are experiencing any pain or discomfort that won’t leave you alone then contact one of our Exercise Physiologists that will provide you with what you need. Look out for the next blog of the POSTURE DEVELOPMENT and PAIN REDUCTION FOR CHILDREN AND YOUTH: how to do it right. Part 3 on the foot and ankle injuries and stability.