Severs

[TimVS]

I am currently treating a 12 yr old male with the classic presentation of Severs, i.e keen football and golf player with BL heel pain, not radiating, pos squeeze test, tight post comp, moderate over pronation (FPI +7ish). I treated him as I usually do - heel lifts, mild stretches, exercise modification, orthoses and, as usual there was a rapid improvement in symptoms with no pain on squeeze L heel, 3/10 pain scale R heel squeeze. So gradually bringing him back to activity, allowing 9 holes golf, no footie until after christmas.
Now then. Saw him last week after long Christmas break and he reports that R heel,pain has returned with a vengeance. Pos squeeze test 8/10 R heel, still clear L heel. Has been playing golf and finds it diff to walk 9 holes. Also struggled walking around TW town (long uphill high street).
This has not happened to me before with Severs, so I'm wondering - have I missed something? Too much activity too soon? (but no footie and only doing 9 holes) Maybe not Severs after all? Stretches too agressive? (but he admits he has not been doing them much) . I have taken the HLs off the orthoses in case they are destabilising the devices - don't think so though and have asked him to refrain from all activity for 2 weeks then see me.
So if there is no improvement should I go for xrays/MRI ? Refer to physio? What would you guys do?

[dtt]

Hi Tim

Have you checked his golf shoes ??
Some of these kids wear ill fitting or conversely the latest all singing all dancing bish bosh 2000 Carlos fandango type which have gizzmos that are frankly inappropriate ( heel rotators to name but one where the heel of the shoe actually move was one short lived trend last year).

They mostly have an "insole" of varying types. Has he been wearing the orthotics on top of and insole with a valgus support or the gell underneath the insole which would give the instability??

What handicap does he play off ??

is he left handed or right handed ??

A right handed golfer puts a lot of strain on the right TA during a golf swing. The low handicap golfer will have the technique to minimise this but the high handicap golfer will (especially males) try to "hit the ball hard" and tend to lunge causing sudden internal rotation of the tib /femur with the foot firmly anchored to the ground with the spikes on the shoes causing a torsional effect on the TA.

It is not uncommon to see a golfer on the first tee (not warmed up ) take an Almighty swing at a ball and collapse in a heap having strained a muscle in the leg.

Just a thought

Cheers mate
Derek

[Admin]

Hi Tim,

To add to dtt's observations.......

I think too much too soon - try ice footbaths for a week (the pt, not you ;D).

Cheers,
David

[robertisaacs]

Saw him last week after long Christmas break and he reports that R heel,pain has returned with a vengeance.

As my learned colleague imply, don't panic just yet.

It could be that you need further investigations, different treatments etc. It coulf be that your initial dx was wrong. Or it could be that they overdid it at christmas and re injured the area.

My advice, when you hear hoofs, think horses not zebra.

First step, as you have done, give it a few weeks to "cool down". It might be a blip. It might be that mum dragged the kid around the Jan sales and he needing something to complain about which she then took seriously.

Second step, review your present interventions to ensure they are being done right. You might find that they did'nt think they had to wear the insoles on days beginning with a T, or that they are stretching twice a week, or too hard. Get them to bring in ALL the shoes they are using and check the insoles are working in all of them

Third step, find out what they have'nt told you. There is very often something lifestyle-y that they "forget" to mention. "oh yes and i do step aerobics at the weekend" style of thing.

Forth step
Go back to the top of the treatment plan and treat it as a new condition (ie start with RICE and go from there)

Only after i've exhausted these things would i start getting exotic.

Regards
Robert

[robertisaacs]

If you want a good essay on diagnostics try watching House md (Hugh laurie). Apart from being tremendously entertaining TV its got some interesting points on how to go about an assessment.

[twirly]

May sound daft but ask him what he recieved for Christmas.

Consider movements involved with the new Wii console.

Just a thought.

Regards

twirls

[robertisaacs]

Consider movements involved with the new Wii console.

I WANT ONE!!!!!

_{But i'm not allowed. Rumph.}


Good point. Might have had heelies! Or been ice skating. Or sat in the same position for 36 hours playing on his nintendo DS.

Regards
Robert

[twirly]

Ah Robert your wife (I'm guessin tis her that said NO) has great sense.

Only reason I thought of Wii was my dear friend has since she purchased hers in December..................................

1) Broken 1 coffee table.
2) Knocked down 1. Christmas tree (twice mind you)
3) Suffered an inversion sprain.
4)Shows symptoms of RSI in her ''running 100 metres against Mario'' wrist!

My beloved aint havin 1 either. I rest my case M'Lud. ;D

[TimVS]

Guys and girls, lots of great ideas, thanks. I'm thinking overuse as the most likely cause - I've just never seen one regress like this. V interesting about the golf - he plays a lot and I never checked his shoes. I'll feed back in a couple of weeks.

Love the Wii idea! We played solidly on our friends' Wii over Christmas - what a fantastic toy. Finally video games are restored to the social arena. My eldest developed tennis elbow and I nearly knocked my wife out perfecting my smash serve !

Cheers,

Tim

[dtt]

Hi Tim

V interesting about the golf - he plays a lot and I never checked his shoe

There is very often something lifestyle-y that they "forget" to mention

If he is like most of the kids at my club, if they are not playing they are practicing !!

Hitting a 1000 balls a day ( yes seriously) on the practice ground during the school holidays he might have forgotten to mention ??

Just a thought

Cheers M8
D

[robertisaacs]

My beloved aint havin 1 either. I rest my case M'Lud. ;D

What if he did this?

[dtt]

Hi Robert

I would say he needs to adjust his grip by strengthening the right paw to get a "draw" on the ball flight coz as it is at the moment he will hit a fade and lose 30 yards on the shot ;D

D

[twirly]

Robert sweet pea it seems you really do not understand us girls at all.




I said NO & I meant NO.


Ever seen a 16stone 6ft 2'' Barnsley crane driver beg?

I have. ;D ;D ;D

N' he still aint gettin' 1.

Note to Bel: Would you give in?

twirl

[blinda]

Only if he was a four legged, fury friend!

[robertisaacs]

Only if he was a four legged, fury friend!

As in very angry?