Sever's Disease (Calcaneal Apophysitis)

Patient information for parents and carers — Dr Christopher Spelman, Orthopaedic Surgeon

What is Sever's disease

Sever's disease, or calcaneal apophysitis, is the most common cause of heel pain in growing children. Like Osgood-Schlatter disease at the knee, it is a “traction apophysitis” – irritation of a growth area, in this case the growth plate at the back of the heel bone (calcaneus), where the powerful Achilles tendon attaches. In a growing child this growth plate is still soft, and the repeated pull of the Achilles tendon during running and jumping, together with impact on the heel, irritates it and causes pain.

It is not an injury or a disease in the usual sense, does not damage the foot, and is self-limiting – it settles once the growth plate at the heel closes.

Who gets it

Sever's disease typically affects children between about 8 and 14 years of age, most often around a growth spurt, and is common in those who play running and jumping sports, particularly on hard surfaces. Both heels are affected in many children. Contributing factors include a tight calf and Achilles tendon, rapid growth, and increases in training load or a change of footwear or surface.

Symptoms

●      Pain at the back or bottom of the heel, brought on by activity and eased by rest

●      Tenderness when the sides of the heel bone are squeezed (the “squeeze test”)

●      Limping or running on the toes after sport, or reluctance to bear weight on the heel

●      Pain that is worse on hard surfaces and with sports involving running and jumping

As with other apophysitis, the pain is activity-related. Heel pain that is present at rest or at night, associated with swelling, redness or fever, or that follows a single significant injury, is not typical of Sever's disease and should be assessed to exclude other causes.

Diagnosis

Sever's disease is diagnosed clinically from the history and examination, particularly a positive heel-squeeze test in a child of the typical age. Imaging is not needed to make the diagnosis. X-rays are reserved for atypical cases – for example, pain not related to activity, a history of significant injury, or symptoms that do not settle as expected – to exclude other causes such as a stress fracture, cyst or infection.

Treatment

Treatment aims to relieve pain while the child continues to be as active as their symptoms allow, and to correct contributing factors such as calf tightness. Effective measures include:

Activity and load management

Reducing the volume of running and jumping during a flare, and using pain as a guide to how much activity is comfortable, rather than stopping sport entirely. Training is then gradually increased as symptoms settle.

Calf stretching and strengthening

A programme of Achilles and calf stretching and progressive strengthening addresses the tightness that drives the condition and is a core part of treatment and return to sport.

Heel cushioning and footwear

Cushioned heel cups or small heel raises reduce the pull on the growth plate and the impact on the heel, and supportive, well-cushioned footwear helps – particularly on hard surfaces. Foot orthoses may help selected children, especially those with associated foot posture issues.

Simple symptom relief

Ice after activity and simple pain relief for flare-ups. In more severe, persistent cases a short period in a walking boot or cast to rest the heel is occasionally used.

Outlook and prognosis

The outlook is excellent. Sever's disease resolves once the growth plate at the back of the heel closes, and it does not cause any long-term problem with the foot. Flare-ups and recurrences during the growing years are common, particularly with increases in activity, but symptoms should not persist beyond skeletal maturity. Physiotherapy and orthotic measures typically allow a return to sport within a couple of months.

Complications

Sever's disease is benign and does not require surgery. The main issues are:

●      Recurrent flare-ups during the growing years, particularly with rapid increases in training load

●      Temporary reduction in sport during flares

There is no long-term damage to the heel, and the condition does not persist into adulthood.

Summary

Sever's disease is the most common cause of heel pain in active, growing children, caused by irritation of the growth plate at the back of the heel where the Achilles tendon attaches. It is managed with load management, calf stretching and strengthening, heel cushioning and simple symptom relief, rarely requires stopping sport completely, and resolves with growth without any lasting harm. Dr Spelman can confirm the diagnosis, reassure you, and exclude other causes where the symptoms are unusual.