Sever’s disease, also called calcaneal apophysitis is an overuse injury and is a common cause of pain at the back of the heel in the skeletally immature children aged 8 to 15 years.
This is usually a self-limiting condition and is something the young athlete should grow out of. Rest is an essential part of treatment, along with ice or cold therapy and managing training loads.
On this page:
- Causes & anatomy
- Expert interview
- Self-help treatment
- Professional treatment
Sever’s disease symptoms
The main symptom of Sever’s disease is pain and tenderness at the back of the heel which is made worse with physical activity. Boys are more commonly affected by Sever’s disease. Symptoms can affect just one foot or both feet at the same time. It affects adolescent children who are often involved in a lot of sports training and physical activity. Tenderness will be felt, especially if you press in or give the back of the heel a squeeze from the sides.
There may be a lump over the painful area which develops over time. It has the classical feature of pain going away after a period of rest from sporting activities only to return when the young person goes back to training. Pain is usually absent first thing in the morning. Another common sign is tight calf muscles which result in a reduced range of motion at the ankle. If the calf muscles are tight, then this increases the traction forces at the back of the heel. Standing on tip-toes will result in an increase in the pain.
Diagnosis of Severe’s disease is usually clinical and does not require any imaging. Although, in some cases, they may require an x-ray to rule out a fracture, a chronic infection, or an extra bony growth around the area.
Similar pain at the back of the heel also occurs in adults but is more likely to be Insertional Achilles tendonitis.
Causes & anatomy
Sever’s disease is often associated with a rapid growth spurt. As the bones get longer, the muscles and tendons become tighter as they cannot keep up with the rate of bone growth. Tight calf muscles reduce the range of motion (dorsiflexion) at the ankle, resulting in more strain on the Achilles tendon and its attachment to the calcaneus or heel bone.
The point at which the Achilles tendon attaches to the heel becomes inflamed and the bone starts to crumble. This is known as apophysitis and is a very similar condition to the more common Osgood Schlatter disease of the knee. When the young person stops growing and the soft tissues have a chance to adjust, then they should grow out of the injury if it is properly managed.
This type of injury can also be brought on by a sudden increase in activity especially involving running or repetitive jumping. Poor cushioning in the shoes or worn out shoes, running on hard surfaces and poor biomechanics of the feet are other factors that can result in this type of injury.
Sever’s Disease treatment
The aim of treatment is to reduce the pain and inflammation at the back of the heel. There is likely to be no magic instant cure and the young athlete may have to be patient while they grow. However, managing training loads to enable the young athlete to continue to get the most of out their sport is essential.
Apply the PRICE principles of protection, rest, ice, compression, and elevation. Rest from any activity which makes the injury worse. Initially, certainly for the first 48 to 72 hours, this will a mean complete rest. If you continue to train on it when it is inflamed and painful, you will make it worse and possibly even cause more 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 better still, use a cold therapy and compression wrap.
Insert a heel pad or heel raise into the shoes. This raises the heel and temporarily shortens the calf muscles, which reduces the traction forces at the back of the heel. However, the long-term use of a heel raise may shorten the calf muscles when they need stretching. 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 or other biomechanical issues which may be contributing to the injury. Whilst the foot is growing, it is a good time to have orthotic insoles professionally fitted as they may encourage normal development of the 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. The condition will usually settle within 6 months, although it can persist for longer.
Sports massage to the calf muscles may be beneficial in reducing any tension and helping the muscle to stretch. Massage directly to the site of pain at the back of the heel should not be done. This will only make the injury worse.
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. This may be a couple of days, it may be longer. Let pain be the guide rather than following strict time limits.
One way to test if the calf muscles, the Gastrocnemius, in particular, are too tight is by gently pushing on the toes to stretch the calf muscles. The foot should go to 90 degrees without having to force it or apply great pressure. If the foot does not go to 90 degrees this may indicate excess tension in the muscles. This is repeated with the knee bent to eliminate the larger gastrocnemius muscle to test the deeper Soleus muscles flexibility.
There are two stretches that are important when stretching the calf muscles. The first one is done with the leg kept straight which stretches the Gastrocnemius muscle, the other is with the knee bent to stretch the Soleus muscle.
Active stretching – this type of stretching will be the safest to use in the early stages of rehabilitation. It involves the patient pulling the foot and toes up gently to stretch the muscles at the back of the leg. Hold for 8 seconds, repeat 5 times. Repeat the stretch throughout the day if pain allows.
Gastrocnemius stretch – keep the heel of the back leg on the ground and gently push forward. If it is painful do not do it. This will stretch the larger Gastrocnemius muscle which originates above the knee joint. This stretch can be held for at least 10 seconds and repeat 3 times. This set of stretching can be done three times a day, more as long as it does not hurt. Some therapists will recommend holding stretches for longer periods of up to 45 seconds.
Soleus muscle stretch – by bending the knee, the Gastrocnemius muscle is taken out of the stretch allowing the Soleus muscle to be stretched further down the leg. But if it hurts, do not do it. Hold this stretch for at least 10 seconds and repeat 3 times. This set of stretching can be done three times a day, more as long as it does not hurt.
The above stretches are all that need to be done for the Achilles and calf muscles. It is the quality of what you do rather than the quantity. Remember that stretching is a long-term process.
Results may not be evident for a few days or even weeks. It is also important to maintain a stretching routine even after the injury has healed.
Managing training schedules with Sever’s disease
The aim of rehabilitation is to gradually increase the load going through the tendon at a rate at which it can cope. When normal daily activities can be done pain-free, training can be resumed. However, modifying the kind of exercise may be necessary to avoid, or at least reduce, the type of training which increases pain. This is likely to include running, jumping, playing football, and any sports which involve this kind of weight-bearing, high-impact activity. It may be necessary to stick to swimming or cycling until the injury has completely cleared up.
However, if changing your sport does not appeal, then try to be more selective with training sessions. For example, a young footballer might take part in some of the high-quality technical practices, or team sessions, but avoid some of the fitness related activities and substitute them for swimming or cycling. It is not ideal, but the main aim is to keep the player in a normal training routine as much as possible whilst avoiding activities which increase heel pain.
If this means training or playing once a week and doing other non-weight-bearing activities for the rest of the week then so be it. Applying ice or cold therapy to the heel on a regular basis after training or exercise, even if it is not painful, may help reduce or prevent any pain and inflammation before it develops.
- 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