A 14-year-old boy presented with a history of heel pain and inability of weight bearing on the heel for three months.
There was evidence of ill-defined hypointensities across the calcaneal epiphysis of the right foot on the T1 W sequence becoming hyperintense on the PDFS sequences. It appeared intermediately hyperintense on the T2W sequence. These bone marrow oedematous signals were seen to extend onto the adjacent calcaneal tuberosity and posterosuperior aspects of the calcaneum. Mild cortical erosions were also seen across the calcaneal tuberosity. The tendo-achilis tendon and its insertion onto the calcaneum appeared normal in signal intensities. Also seen were ill-defined oedematous signals across the talus. Mild joint effusion was also noted across the tibio-talar joint.
Calcaneal apophysitis, also known as Sever’s disease or avascular necrosis of calcaneal epiphysis, is a commonly encountered entity amongst athletic children and is frequently undiagnosed [1]. It is an inflammation caused by the traction of the achilles tendon on the unossified calcaneal apophysis. It is usually seen in the age group of 8-15 years at the peak of growth spurt when children begin to actively participate in new sports. Clinically no obvious swelling, skin changes, erythema or local abnormalities are seen. The child typically presents with heel pain and inability of weight bearing.
The initial diagnostic approach of X-ray and ultrasound are nonspecific. On plain radiograph the apophysis may appear normal or may reveal mild irregularity and fragmentation of the apophyseal margin. Osteoporotic patches, sclerosis, and mild widening of the involved apophyseal area can also be seen in some cases. Radiographs are often obtained to exclude other conditions like fracture, tumours, osteomyelitis, etc. [2, 3]. On ultrasound apophysis is seen as a heterogeneous vascularized pseudomass, representing the inflamed apophysis. Nuclear scintigraphy findings in apophysitis are nonspecific. Increased radiotracer uptake in the apophysis on blood pool and delayed images has been described. CT findings usually show epiphyseal widening, irregularity, and fragmentation of the apophyseal margin. MR evaluation of apophysitis should be done in two planes: axial and sagittal or coronal. A combination of fast spin-echo T1-weighted and fat-suppressed fast spin-echo T2-weighted or STIR sequences should be performed [2]. On MR there is increased signal intensity on watersensitive sequences in the apophysis, subjacent bone marrow, and adjacent muscle and fibrous periapophyseal structures (tendon, ligaments, capsule, bursae). There is contrast enhancement of the apophysis, epiphyseal plate, subjacent bone, and surrounding soft-tissue structures [2].
The condition usually resolves within two weeks of conservative treatment. In more severe cases nonsteroidal anti-inflammatory drugs may be given.
Sever’s disease or calcaneal apophysitis.
Abnormal signals are observed in the posterior portion of the calcaneus (calcaneal apophysis region) on the sagittal and axial MRI sequences of the ankle:
The aforementioned imaging features are primarily localized to the calcaneal apophyseal region. No notable abnormalities are observed affecting the adjacent articular surfaces or distal soft tissues.
Taking into account that the patient is an adolescent, presents with primary symptoms of heel pain, and exhibits clear inflammatory signals in the calcaneal apophysis on imaging, the following diagnoses are considered:
Based on the following factors, the most likely diagnosis is calcaneal apophysitis (Sever’s disease):
If clinical uncertainty persists or atypical symptoms arise, additional evaluations—such as bone metabolism markers, serological tests, or follow-up MRIs—may be considered to exclude other rare conditions.
Adhere to the FITT-VP principles (Frequency, Intensity, Time, Type, Progression, Volume):
Throughout rehabilitation, special attention should be paid to relieving Achilles tendon tightness and supporting the foot to prevent recurrence.
Disclaimer: This report provides a reference-based analysis derived from the given medical history and imaging data. It should not replace an in-person consultation or professional medical advice. If further questions arise, please consult an orthopedic or sports medicine specialist promptly.
Sever’s disease or calcaneal apophysitis.
