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

Abstract

The purpose of this study was to investigate whether the identification of Sever's disease is reliable with radiographs alone. Eighty foot radiographs (50 boys with calcaneal apophysitis and 30 healthy boys) were included in this study. Two consultant orthopaedic surgeons were instructed to make a diagnosis without clinical information on the patients. Radiologic assessments were performed in random order by each observer on two separate occasions, at least 3 weeks later. kappa-statistics were used to establish a relative level of agreement between observers for the two readings and between separate readings by the same observer. Observer A made 22 true (27.5%) diagnoses, whereas observer B made 56 true (70%) diagnoses at the first assessment. Interobserver agreement was rated as slight (kappa-value, 0.190). Observer A made 40 true (50%) diagnoses, whereas observer B made 52 true (65%) diagnoses at the second assessment. Interobserver agreement was rated as slight (kappa-value, 0.039). Intraobserver reproducibility was rated as fair for both observers (kappa-value, 0.369 for observer A and 0.253 for observer B). The results of this study showed that the radiologic identification of calcaneal apophysitis without the absence of clinical information was not reliable. Radiologic findings that were attributed to Sever's disease showed a wide variation between independent observers and between separate readings by the same observer. The diagnosis of calcaneal apophysitis is a clinical decision and radiographic assessment seems to be unnecessary.

Treatment outcomes of adolescents with Iselin’s apophysitis

“…However, Ralph et al [5] and Canale et al [1] suggest that the true incidence of Iselin's may be underestimated. Finally, apophysitis of the tibial tubercle, calcaneus, and base of the fifth metatarsal have been referred to as 'diseases' in prior studies [1,[10][11][12]. In our experience, the term 'disease' heightens parental anxiety.…”

Calcaneal Apophysitis (Sever's Disease): MRI Findings

“…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 .…”

“…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 .…”

“…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 .…”