Sever’s disease, also called calcaneal apophysitis is an overuse injury and a common cause of pain at the back of the heel in children aged 8 to 15 years. Here we explain the symptoms, causes, and treatment, as well as how to manage training for young athletes who suffer with it.
Sever’s disease symptoms
Sever’s disease mostly affects adolescent children who are involved in a lot of sports training and physical activity.
- The main symptom of Sever’s disease is pain and tenderness at the back of the heel
- Pain is made worse with physical activity and may improve with rest.
- Boys are more commonly affected by Sever’s disease.
- Symptoms can affect just one foot or both feet at the same time.
- Pain is often reduced first thing in the morning and gradually gets worse during the day.
A typical feature of Sever’s disease is pain will go away after a period of rest, only to return when you go back to training.
A professional therapist will do a number of tests along with case history and activity/training levels to help diagnose Sever’s disease.
- Pressing in at the back of your heel, or squeezing the heel from both sides will be painful.
- A painful lump may develop at the back of your heel.
- Another common sign is tight calf muscles. If your calf muscles are tight, then they pull harder at the back of your heel.
Severe’s disease is usually easy to diagnose and does not require any imaging. However, in some cases, you may require an x-ray to rule out a fracture, a chronic infection, or an extra bony growth around the area.
What else might it be?
- Similar pain at the back of the heel also occurs in adults but is more likely to be Insertional Achilles tendonitis.
What is Sever’s disease?
Sever’s disease is often associated with a rapid growth spurt. As your bones get longer, the muscles and tendons become tighter. This is because they cannot keep up with the rate of bone growth. Tight calf muscles reduce the range of motion (dorsiflexion) at your ankle, resulting in more strain on your Achilles tendon, especially at its attachment to the calcaneus or heel bone.
The point at which the Achilles tendon attaches to your calcaneus (heel bone) becomes inflamed and the bone starts to crumble. This is known as apophysitis and is a very similar condition to Osgood Schlatter disease of the knee.
When you stop growing and the soft tissues have a chance to adjust, you should simply grow out of it, if properly managed.
What causes Sever’s disease?
- This type of injury can be brought on by a sudden increase in activity, especially running or repetitive jumping.
- Poor cushioning in your footwear, shoes which are worn out or inappropriate for your particular sport can all increase your chances of developing Sever’s disease.
- Running on hard surfaces, especially if it is a sudden change of surface.
- Poor foot biomechanics. If your foot overpronates (rolls in & flattens), then your Achilles tendon will twist. Therefore, increasing the pulling forces at the back of your heel.
Will I grow out of Sever’s disease?
Elite Physiotherapy Consultant Neal Reynolds explains growing pains in young footballers.
Sever’s Disease treatment
- The aim of treatment is:
- To reduce the pain and inflammation at the back of your heel.
- Manage and adapt training to enable an injured young athlete to get optimum benefit out of the pain-free training they are able to do.
There is no instant, magic cure. You have to be patient and adapt training until you grow out of it.
- Apply the PRICE principles of protection, rest, ice, compression, and elevation.
- Rest from any activity which makes the injury worse.
- Initially, for the first 48 to 72 hours, this means complete rest.
- If you continue to train on it a painful and inflamed heel, you will make it worse and possibly even cause permanent damage to the bone.
- Apply ice or cold therapy for 10 mins every hour initially, reducing the frequency as symptoms improve.
- Do not apply ice directly to the skin unless it is in the form of ice massage. Ice massage involves massaging an ice cube over the site of pain, ensuring the ice is not kept continually in once place.
- Ice can also be wrapped in a wet tea towel or use a cold therapy and compression wrap.
- Insert a heel pad or heel raise into your shoes. This raises your heel and temporarily shortens the calf muscles, reducing traction forces at the back of your heel.
- Make sure you place them in both shoes, even if only one heel is painful, as just putting in one will cause a leg length difference and may increase the chance of other injuries to the lower leg, hips and back.
What can a professional do?
- A doctor or physiotherapist can apply a plaster cast or boot if the child is in severe pain. This may be worn for a few days or even weeks and should give relief of pain for a while.
- They will carry out a full biomechanical assessment to help determine if any foot biomechanical issues are contributing to the condition.
- Orthotics or insoles can be prescribed to help correct overpronation.
- It is a good time to have orthotic insoles professionally fitted whilst you are still growing. This is because they may encourage normal development of your foot.
- A doctor may prescribe anti-inflammatory medication, such as ibuprofen to reduce pain and inflammation. This will not be prescribed if the child has asthma.
- In persistent cases, X-rays may be taken, but this is not usual.
- A sports injury professional will NOT give a steroid injection or operate as these are not suitable treatment options.
- Sports massage to the calf muscles may be beneficial in reducing any tension and helping the muscles to stretch. Massage directly to the site of pain at the back of the heel should never be done. This will only make your injury worse.
How long does Sever’s disease take to go away?
- The condition will usually settle within 6 months, although it can persist for longer.
- You may find it comes and goes over a period of years, often for no apparent reason.
Exercises for Sever’s disease
- When pain allows, exercises to stretch the calf muscles at the back of the lower leg should be done.
- In the long-term, this will reduce traction forces at the back of the heel.
- This should only be done if the foot is free from pain. If it is painful then ‘tugging’ at the back of your heel will only make it worse.
- Let pain be the guide rather than following strict time limits.
- Sever JW. Apophysitis of the os calcis. NY Med J 1912;95:1025.
- Ogden JA, Ganey TM, Hill JD et al. Sever’s injury: a stress fracture of the immature calcaneal metaphysis. J Pediatr Orthop 2004;24:488-93
- Ramponi DR, Baker C. Sever’s Disease (Calcaneal Apophysitis) Adv Emerg Nurs J. 2019 Jan/Mar;41(1):10-14