Sever’s disease is juvenile osteochondrosis of calcaneus, manifested with posterior heel pain and mild swelling, usually in young athletes, caused by repetitive microtrauma. The standard diagnostic procedures include radiographs and ultrasound examination. It is a self-limiting condition, usually treated conservatively. We present a case of Sever’s disease complicated with calcaneal osteomyelitis. A 9-year-old boy with a several month history of left heel pain was admitted to our institution for further clinical evaluation and therapy. Bilateral Sever’s disease was clinically diagnosed, confirmed by radiographs and ultrasound examination. Magnetic resonance imaging (MRI) showed osteolytic zone in the posterior left calcaneus with peripheral enhancement after contrast administration and surrounding bone and subcutaneous edema, suggestive of osteomyelitis. After six weeks of parenteral antibiotic treatment, the patient’s condition improved. Follow up MRI performed 3 months later showed significant regression of osteolytic lesion and replacement with granulation tissue surrounded with new bone formation. To our knowledge and literature search, this is a previously unreported complication of Sever’s disease. MRI should be done in all atypical cases of Sever’s disease to rule out any other possible disorders including osteomyelitis.Severova bolest je juvenilna osteohondroza petne kosti koja se manifestira bolovima i oteklinom u stražnjem dijelu pete, najčešće u mladih sportaša, uzrokovana opetovanim mikrotraumama. Slikovna dijagnostička obrada uključuje rendgenske snimke i ultrazvučni pregled. Bolest se liječi konzervativno, budući da prolazi sama od sebe. Prikazali smo devetogodišnjaka sa Severovom bolesti kod kojega standardna terapija nije polučila klinički učinak. Učinjen je pregled pete magnetskom rezonancijom (MR) koji je pokazao Severovu bolest i osteomijelitis petne kosti. MR pregled pete bi trebalo učiniti u svim atipičnim slučajevima Severove bolesti kako bi se isključila druga patološka stanja uključujući osteomijelitis

Dijana Zadravec

Dragan Lepur

Igor Borić

Klaudija Višković

Matej Mustapić

English

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252 Acta Clin Croat,  Vol. 53,   No. 2,  2014Acta Clin Croat 2014; 53:252-255 Case Report SEVER’S DISEASE COMPLICATED WITH OSTEOMYELITISMatej Mustapić1, Igor Borić2, Dragan Lepur3, Dijana Zadravec1 and Klaudija Višković41Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Zagreb; 2Department of Radiology, Sveta Katarina Special Hospital, Zabok; 3Department of Intensive Care Medicine and Neuroinfectology, 4Department of Radiology and Ultrasound, University Hospital for Infectious Diseases, Zagreb, CroatiaSUMMARY – Sever’s disease is juvenile osteochondrosis of calcaneus, manifested with poste-rior heel pain and mild swelling, usually in young athletes, caused by repetitive microtrauma. The standard diagnostic procedures include radiographs and ultrasound examination. It is a self-limiting condition, usually treated conservatively. We present a case of Sever’s disease complicated with cal-caneal osteomyelitis. A 9-year-old boy with a several month history of left heel pain was admitted to our institution for further clinical evaluation and therapy. Bilateral Sever’s disease was clinically diagnosed, confirmed by radiographs and ultrasound examination. Magnetic resonance imaging (MRI) showed osteolytic zone in the posterior left calcaneus with peripheral enhancement after contrast administration and surrounding bone and subcutaneous edema, suggestive of osteomyelitis. After six weeks of parenteral antibiotic treatment, the patient’s condition improved. Follow up MRI performed 3 months later showed significant regression of osteolytic lesion and replacement with granulation tissue surrounded with new bone formation. To our knowledge and literature search, this is a previously unreported complication of Sever’s disease. MRI should be done in all atypical cases of Sever’s disease to rule out any other possible disorders including osteomyelitis.Key words: Sever’s disease; Calcaneus; Osteomyelitis; Diagnostic imaging; Case reportCorrespondence to: Matej Mustapić, MD, Department of Diagno-stic and Interventional Radiology, Sestre milosrdnice University Hospital Center, Vinogradska c. 29, HR-10000 Zagreb, CroatiaE-mail: mmustapicm@gmail.comReceived May 14, 2013, accepted July 8, 2013IntroductionSever’s disease (calcaneal apophysitis, juvenile os-teochondrosis of calcaneus) is a painful, self-limiting condition, usually in young athletes, which can inter-fere with walking and physical performance in sports. It usually occurs in active 10- to 12-year-old boys. It was first described by Sever in 1912, as inflammation of the calcaneal apophysis, resulting in pain at the posterior heel with mild swelling and difficulty with walking1. The disease is bilateral in 60%-80% of cases. The etiology of Sever’s disease is believed to be repeti-tive trauma to the weaker structure of the apophysis, caused by traction in the opposite direction between Achilles tendon and plantar structures, causing in-flammation2,3. The anatomy of calcaneal apophysis is a contributing factor for significant shear stress because of its vertical orientation and the direction of pull from the strong gastrocnemius-soleus muscle group. This results in a clinical picture of heel pain in a grow-ing active child, which worsens with activity, espe-cially running or jumping, and relieves with rest. The onset of the disease is usually gradual. The diagnosis is provided by physical examination with characteristic history in specific age group, confirmed by x-ray and ultrasound. The treatment is initially focused on re-ducing the pain and movement limitations, and then on preventing recurrence. Limitation of activity (es-pecially running and jumping) is usually necessary. In patients with symptoms that are not severe enough to limit sports activities, wearing an inner-shoe heel Acta Clin Croat,  Vol. 53,   No. 2,  2014 253M. Mustapić et al. Sever’s disease and osteomyelitislift, a monitored stretching program, icing, and anti-inflammatory agents normally reduce the symptoms4. To prevent recurrence, a good pre-exercise stretching program is obligatory.Fig. 1. Sagittal fat-suppressed proton density weighted image of the left heel shows osteolytic lesion in the posterior part of the calcaneus and fragmented apophysis, with sur-rounding bone marrow and subcutaneous edema.Fig. 2. Sagittal contrast-enhanced fat-suppressed T1 weighted image reveals osteolytic lesion in the left calca-neus with hypointense center and rim enhancement due to abscess formation.Fig. 3. Sagittal fat-suppressed proton density weighted im-age of the right heel shows mild edema of calcaneal apophy-sis with sclerosis and fragmentation of ossification center.Case ReportA 9-year-old Caucasian boy with a several month history of left heel pain was admitted to the hospital because of Sever’s disease. Four months earlier, he had started complaining of pain in his right heel, which was relieved with symptomatic therapy. One month before admission, he also started complaining of pain in his left heel, after minor contusion of the left foot. Radio-graphs of the ankle and heel showed neither fracture nor dislocation, but bilateral sclerosis and fragmenta-tion of calcaneal apophysis were present. According to clinical and radiographic findings, Sever’s disease was diagnosed and confirmed by ultrasound examination. Physical therapy and non-steroidal anti-inflammatory drugs were recommended. Since pain in the left heel was not relieved with therapy, he was admitted to the hospital for further diagnostic procedures. On admis-sion, physical examination showed left heel swelling and painful Achilles insertion with deep palpation. Except for elevated erythrocyte sedimentation rate (26 mm/1 h), elevated C-reactive protein (52 mg/L) and highly positive antistreptolysin-O titer (2560 units/mL), other relevant laboratory values were normal. Magnetic resonance imaging (MRI) of the patient’s feet showed osteolytic zone in the posterior left calca-254 Acta Clin Croat,  Vol. 53,   No. 2,  2014M. Mustapić et al. Sever’s disease and osteomyelitisneus with peripheral enhancement after contrast ad-ministration and surrounding bone and subcutaneous edema, compatible with osteomyelitis (Figs. 1 and 2). Apophysis was fragmented and sclerotic. There were also signs of calcaneal apophysitis of the right heel (Fig. 3). After six weeks of parenteral treatment (with clindamycin), the patient’s condition significantly improved. Follow up MRI performed 3 months later showed significant regression of the osteolytic lesion and replacement with granulation tissue surrounded with new bone formation (Figs. 4 and 5). Minimal bone edema was present.Discussion and ConclusionAccording to literature search, this is the first case report of Sever’s disease complicated with calcaneal osteomyelitis. The obvious asymmetry of physical findings and clinical symptoms, as well as different response to symptomatic therapy was quite unusual in this case. Most patients experience pain with deep palpation at the Achilles insertion and pain when performing toe and ankle dorsiflexion that is relieved with passive equinus positioning. Swelling may be present but is usually mild. Radiographic appearance Figs. 4 and 5. Sagittal fat-suppressed proton density weighted image and sagittal T1 weighted image of the left heel show significant regression of osteolytic lesion in the calcaneus, replacement with granulation tissue surrounded with new bone formation and minimal bone edema.of resorption, fragmentation, and increased sclerosis of calcaneal apophysis, leading to eventual union, can be seen. The radiographs showing fragmentation of calcaneal apophysis are not by themselves a diagnostic tool in asymptomatic child because multiple centers of ossification may exist in the normal apophysis as well5. The diagnosis of calcaneal apophysitis is a clini-cal decision with characteristic but not specific signs on x-rays. Besides apophyseal fragmentation, edema of the Achilles tendon at insertion and retrocalcaneal bursitis as well as subcutaneous edema can be seen on ultrasound examination6. Differential diagnosis of Sever’s disease includes Achilles tendon pathology, calcaneus fracture, rarely bone tumor, tarsal coali-tion, and possibly osteomyelitis7. The question arises whether the osteomyelitis, in this case, is a separate entity or a true complication of Sever’s disease. Cal-caneus is a rare location for bone infections in chil-dren. The calcaneal apophysis can be considered as a metaphyseal region of long bones, leading to bone vulnerability to hematogenous infection, especially if apophysitis is present8. Taking into consideration all the above mentioned facts and patient’s history, we find osteomyelitis to be the true complication of Sev-er’s disease in this case. In all atypical cases of Sever’s Acta Clin Croat,  Vol. 53,   No. 2,  2014 255M. Mustapić et al. Sever’s disease and osteomyelitisdisease, with unusual presentation and disease course, MRI should be performed to rule out osteomyelitis and alternative diagnoses.References1. LAU LL, MAHADEV A, HUI JH. Common lower limb sport-related overuse injuries in young athletes. Ann Acad Med Singapore 2008;37(4):315-9.2. HENDRIX CL. Calcaneal apophysitis (Sever disease). Clin Podiatr Med Surg 2005;22(1):55-62.3. HACKNEY AC, KOLTUN KJ. The immune system and overtraining in athletes: clinical implications. Acta Clin Cro-at 2012;51(4):633-41.SažetakSEVEROVA BOLEST KOMPLICIRANA OSTEOMIJELITISOMM. Mustapić, I. Borić, D. Lepur, D. Zadravec i K. ViškovićSeverova bolest je juvenilna osteohondroza petne kosti koja se manifestira bolovima i oteklinom u stražnjem dijelu pete, najčešće u mladih sportaša, uzrokovana opetovanim mikrotraumama. Slikovna dijagnostička obrada uključuje rendgenske snimke i ultrazvučni pregled. Bolest se liječi konzervativno, budući da prolazi sama od sebe. Prikazali smo devetogodišnja-ka sa Severovom bolesti kod kojega standardna terapija nije polučila klinički učinak. Učinjen je pregled pete magnetskom rezonancijom (MR) koji je pokazao Severovu bolest i osteomijelitis petne kosti. MR pregled pete bi trebalo učiniti u svim atipičnim slučajevima Severove bolesti kako bi se isključila druga patološka stanja uključujući osteomijelitis.Ključne riječi: Severova bolest; Kalkaneus; Osteomijelitis; Slikovna dijagnostika; Prikaz slučaja4. PECK DM. Apophyseal injuries in the young athlete. Am Fam Physician 1995;51(8):1891-5, 1897-8.5. KOSE O. Do we really need radiographic assessment for the diagnosis of non-specific heel pain (calcaneal apophysitis) in children? Skeletal Radiol 2010;39(4):359-61.6. HOSGOREN B, KOKTENER A, DILMEN G. Ultra-sonography of the calcaneus in Sever’s disease. Indian Pediatr 2005;42(8):801-3.7. DAMIANO J, BOUYSSET M. Hindfoot pain. Rev Prat 2010;60(3):353-60.8. JENZRI M, SAFI H, NESSIB MN, et al. Hematogenous osteomyelitis of the calcaneus in children: 26 cases. Rev Chir Orthop Reparatrice Appar Mot 2008;94(5):434-42.

Severova bolest komplicirana osteomijelitisom

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